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ill! 









V 



HOSPITALS 



DISPENSARIES 



AND 



NURSING 



Papers and Discussions in the International Congress of 

Charities, Correction and Philanthropy, Section 

III, Chicago, June i2th to 17TH, 1893 






« •• fl » 



EDITED BY 



JOHN S. KILLINGS, M. D. 
HENRY M. HURD, M. D. 




f 



BALTIMORE 
The Johns Hopkins Press 

LONDON 
The Scientific Press, Limited 

498 Strmnd, W. C. 
1894 



COPTBieBT, IWM, BT THB JoRNB HoPKIMB VKMM. 



» • • • * 

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• • • 

• • ••• 



• • • 



• • • 



THB FUIBDKMWALD CO., PRINTXRA, 
BALTIMOBX. 






INTERNATIONAL CONGRESS OF CHARITIES, 
CORRECTION AND PHILANTHROPY. 



SECTION III. 



The Hospital Care of the Sick, Training of Nurses, Dispensary 

Work, and First Aid to the Injured. 

Honorary Chairman : 

Mr. Henry C. Burdett, 

London, Eng. 
Honorary Vice-Chairman : 

Lieutenant-Colonel J. Lane Notter, M.A., M.D., 

Surgeon-Major British Army, Netley, Eng. 
Chairman : 

John S. Billings, M. D., LL. D. Edin. and Harv., D. C. L. Oxon. 

Surgeon U. S. A., Washington, D. C. 
Secretary : 

Henry M. Hurd, M.D., 

Superintendent, The Johns Hopkins Hospital, Baltimore, Md. 



NUBSING SUBSECTION. 

Honorary Chairman : 

Miss Amy Hughes, 

Superintendent of the Metropolitan and National Nursing Association, London. Eng. 

Honorary Vice-Chairmen : 

Miss E. P. Davis, 

Superintendent of the University of Pennsylvania Hospital, Philadelphia, Pa. 

Miss Irene Sutliffe, 

Directress of Nurses, New York Hospital, New York. 

Chairman : 

Miss Isabel A. Hampton, 

Supertntendeot of Nurses and Principal of Training School, The Johns Hopkins Hospital, 

Baltimore, Md. 

Secretary : 

Miss Emma Cameron, 

Assistant Superintendent Illinois Training School for Nurses, Chicago, 111. 



47681 



PRELIMINARY NOTICE. 



The papers and discussions herewith presented constitute the 
transactions of Section III of the International Congress of Charities, 
Correction and Philanthropy, which was held in Chicago, from June 
12 to 17, 1893, under the auspices of the World's Congress Auxiliary 
of the World's Columbian Exposition. On Wednesday, June 14th, 
Section III, through its chairman, Dr. John S. Billings, of Washing- 
ton, had charge of one of the general sessions of the Congress, at 
which time papers were presented by the chairman on the '* Relations 
of Hospitals to Public Health"; by Lord Cathcart, of London, on 
the "Medical Charities of the English Metropolis"; by Miss Isabel 
A. Hampton, of Baltimore, on "Educational Standards for Nurses"; 
by Mr. Henry C. Burdett, of London, on "Hospital Finance and 
Method of Keeping Accounts,'* and by Lieut.-Col. J. Lane Notter, 
Professor of Military Hygiene, Army Medical School, Netley, on the 
"Applicability of Hygiene to the Conditions of Modern Warfare." 

Sectional meetings were also held, at which papers were pre- 
sented as follows : 

Monday, June 12, 2 p. m. (Nursing Subsection included). 

Organization of the Section. 

»*The Trustee of the HospiUl," Mr. Richard Wood, Philadelphia. 

**The Relation of Training Schools to Hospitals,'* Miss L. L. Dock, 
Baltimore. 

**The Relation of the Medical Staff to the Governing Bodies in Hos- 
pitals,'* Dr. £dward Cowles, Somerville, Mass. 

*' Hospital Administration,*' Dr. H. Merke, Director Krankenhaus Moabit, 
Berlin. 

"The Relation of Hospitals to Medical Education,** Dr. Henry M. Hurd, 
Baltimore. 

Tuesday, June 13, 10.30 a.m. 

" Hospital Accounts and Methods of Bookkeeping,'* Mr. James R. Lathrop, 

New York. 
"On Paying Patients in Hospitals,*' Dr. H. M. Lyman, Chicago. 



VI PRELIMINARY NOTICE. 

" Paris Free and Paying Hospitals,** Drs. Alan Herbert and W. Douglas 

Hogg, Paris. 
** Isolating Wards and Hospitals for Infectious Diseases/* Dr. G. H. M. 

Rowe, Boston. 
''Dispensaries Historically and Locally Considered,** Mr. Charles C. 

Savage, New York. 

Tuesday, June 13, 2 p. m. 

"On the Utility, Peculiarities and Special Needs of Hospitals for Chil- 
dren,** Dr. William Wallis Ord,'London. 

" Ueber Milit^rlazarethe,** Dr. Grossheim, German Army. 

** Naval Hospitals,** Dr. James D. Gatewood, Surgeon, U. S. Navy. 

"The Marine Hospital Service,'* Dr. G. W. Stoner, Baltimore. 

" Detention Hospitals for the Insane,** Dr. Matthew D. Field, New York. 

" Hospital Plans '* (illustrated by Stereopticon Views), Dr. L. S. Pilcher, 
Brooklyn. 

"Cottage Hospitals,'* Mr. Francis Vacher, Birkenhead, England. 

"The Construction of Maternity Hospitals,** Dr. B. C. Hirst, Philadel- 
phia. 

"Hospitals for Infectious Diseases," Dr. C. F. M. Pistor, Geheimer Med- 
icinal-Rath, Berlin. 

" Isolation Wards and Hospitals for Contagious Diseases,** Dr. Alan 
Herbert and Dr. W. Douglas Hogg, Paris. 

Thursday, June 15, 10.30 a. m. (Nursing Subsection included). 

•* French Training Schools," Dr. Leon Le Fort, Paris. 

" Systems of Hospital Nursing in Amsterdam," Dr. Edouard Stumpf, 
Amsterdam. 

" Nurses* Homes,** Miss K. L. Lett, Chicago. 

" Hospital for Contagious and Infectious Diseases,*' Dr. M. L. Davis, 
Lancaster, Pa. 

"A Description of the proposed new Laundry of the University of Penn- 
sylvania Hospital,** Dr. A. C. Abbott, Philadelphia. 

" Diet Kitchens in Hospitals,*' Dr. H. B. Stehman, Chicago. 

** Hospital Dietaries,** Miss M. A. Boland, Baltimore. 

Friday, June 16, 10 a. m. 

** First Help in Hemorrhage,** Prof, von Esmarch, Germany. 
"First Aid to the Injured and how it should be Taught,*' Dr. Henry G. 
Beyer, Surgeon, U. S. Navy. 
First Aid to the Injured from the Military Standpoint,'* Dr. Charles 

Smart, Surgeon, U. S. Army. 
Organization of First Aid to the Wounded in Paris,** Drs. Alan Herbert 
and W. Douglas Hogg, Paris. 
"The Ambulance System of New York,** Mr. George P. Ludlam, New 
York. 



(i 



(( 



PRELIMINARY NOTICE. Vll 

*'An Easy Method of Bedmaking and Improved Stretcher for Hospital and 
Military Use,*' Dr. £. D. Worthington, Sherbrooke, Quebec. 

''A Short Sketch of the Chilian Hospitals," Dr. Luis Asta-Buruaga, Val- 
paraiso. 

" Hospital Saturday and Sunday," Mr. Frederick F. Cook, New York. 

Descriptions were also presented of the Montreal General Hospital ; the 
Roosevelt Hospital, N. Y.; the Johns Hopkins Hospital, Baltimore, and the 
Koyal Victoria Hospital, Montreal, which were ordered to be published. 

The sessions and papers of the Subsection on the Training of 
Nurses were as follows : 

June 15, 10,30 a. m. 

** Trained Nursing in Berlin," Fraulein Luise Fahrmann, Berlin, Germany. 
** La Source Normal Evangelical School of Independent Nurses for the 

Sick at Lausanne, Switzerland," Dr. Charles Krafft. 
'* Nursing Work of the Religious Orders of the Roman Catholic Church,'' 

Cardinal Gibbons. 
*'The Education of Nurses in the Catholic Religious Orders of Germany," 

Sanitatsrath Dr. K5IIen, Berlin. 
"Nursing in Scotland," Miss Rachel Frances Lumsden, Aberdeen. 
*' The Work of Deaconesses in Germany." 

''Training Schools in America," Miss Irene Sutliffe, New York. 
** Proper Organization of Training Schools in America," Miss Louise 

Darche, New York. 
** Nurses as Heads of Hospitals," Miss E. P. Davis, Philadelphia. 

June 14, 2 p.m. 

** Needs for an American Nurses' Association," Miss Edith Draper, 

Chicago. 
**Tbe Royal National Pension Fund for Nurses," Miss Gordon, London. 
*' Alumnse Associations for Nurses," Miss Isabel Mclsaac, Chicago. 
** District Nursing in England," Mrs. Dacre Craven, London. 
" The Work of the Queen's Institute," Miss A. Hughes, London. 
** District Nursing in America," Miss C. E. Somcrville, Lawrence, Mass. 
*' Missionary Nursing in Japan and China," Miss L. Richards, Boston, Mass. 

June 16, 10.30 a. m. 

** Children's Hospitals," Miss Rogers, Washington, D. C. 
*• Obstetric Nursing," Miss Pope, Washington, D. C. 

Midwifery as a Profession for Women," Mrs. Henry Smith, London. 

The Nursing of the Insane," Miss May, Rochester, N. Y. 



*4 
•i 



June 17, 3 p. m. 

** Association for the Training of Attendants," Mrs. D. lU Kinney, Boston, 
Mass. 



Vlll PRELIMINARY NOTICE. 

** The Instruction of the Sisters of the Red Cross," Dr. Goering, Bremen, 

Germany. 
*' Training Schools for Small Hospitals," Miss M. Greenwood, Cincin- 
nati, Ohio. 
*' The London Hospital Nurses' Home," Miss Eva C. £. LUckes, London. 

There were also presented, as part of the work of the Congress, through 
Baroness Burdett-Coutts, papers from Florence Nightingale, the Hon. Mrs. 
Stuart Wortley and Miss Louisa Twining. 



TABLE OF CONTENTS. 



• 



rACB 

Officers of Section Three iii 

Preliminary Notice v 

I. — General Session. 

The Relations of Hospitals to Public Health. By John S. Billings. 

M.D I 

The fttedical Charities of the English Metropolis. By Lord Cath- 

CART 7 

Educational Standards for Nurses. By Isabel A. Hampton .... 31 
Hospital Finance and Method of Keeping Accounts. By Henry C. 

BURDBTT 42 

The Applicability of Hygiene to the Conditions of Modern Warfare. 

By LiEUT.-CoL. J. Lane Notter, M. A., M. D 46 

II. — Sectional Meetings. 

The Trustee of the Hospital. By Richard Wood 54 

Discussion 65 

The Relations of the Medical Staff to the Governing Bodies in Hos- 
pitals. By Edward Cowlbs, M. D 69 

Ueber die Verwaltung von Krankenh&usern. By Dr. H. Merks ... 76 

The Relation of Training Schools to Hospitals. By L. L. Dock ... 86 

Discussion 96 

The Relation of Hospitals to Medical Education. By Henry M. 

HuRD, M. D 98 

Discussion 105 

Hospital Accounts and Methods of Bookkeeping. By James R. 

Lathrop 106 

Discussion 120 

On Paying Patients in Hospitals. By Henry M. Lyman, M. D. . . . 124 

Discussion 127 

Isolating Wards and Hospitals for Infectious Diseases. By G. H. M. 

Rowe, M.D 132 



K CONTENTS. 

GrundiUgc fUr Bau, Einiichlung und Verwallung von Absonderoogf- 

rSumcn uod Sonderkrankenh^usern fQr ansteckcnde Ktankheiten. 

By Dk. MoRi'i'i i'lSTOR 141 

Isolatian Wards and Hospital for Contagioas Diseases in Puis. By 

Alan Hbrbkbt, U.M., and W. UooG^ABHooG, D.M i5j 

Paris Free and Payiog Hospitals. By ALAN Herbkrt, D. M., and 

W. Douglas Hogg, D. M 171 

Hospital for Coniagioug and Infeelious Diseases. By M. L. Davis, 

M.D 175 

Diet-Kitchens in Hospitals. By H. fi. Stshuan, M. D 1S4 

Hospital Dietaries. By M. A. Buland 1S9 

«3 

I of the proposed new Laundry of tbe University of Fenn- 

>Bpital. By A. C. Abbott. M. D 204 

Notes OD Naval Hospitals, Medical Schools, and Training School for 
Nurses, with a Sketch of Hospital HiHtory, By J. D. Gat«wood. 

M. D »12 

Discassion . . igo 

Uebcr Mililirlazarcthe. By Dm. GittJssHKiM 190 

The United States Marine Hospital Service. By G. W. SroNKN, M. D. 29S 

Discussion 31B 

Hospital Constrtiction illustrated by Slercoplicon Views, liy L. S. 

PlLCHER,M.D 3rg 

Detention Hospitals for the Insane. By Mai-thhw D. Field, M. D. . . 320 
TheConstructionof Maternity Hospitals. By BAkloN C. Hikst, M. D. 32S 

Cottage Hospitals. By Fkancis Vachek 332 

Ueber den Bau Ton Kinderkrankcnbausern, Isolirung und Vethtltung 
Uebertragung von Infectionskrankheilen, VerpSegung der Kranken. 

By Ds. A. Baginsky 353 

The Utility. Pectiliaiities and Special Needsof Hospitals for Children. 

By W. W, Obd, M. D 363 

Children's Hospitals in America. By M. L. Kogers 373 

Tokyo Charily Hospital. By K. Takaki, F, K. C. S 379 

A Short Sketch of the Chilian Hospitals. By Louis Asta-Bukuaga, 

M.D 381 

The Hospital Care oi the Sick and the Training of Nurses at Amater- 

dain. By Edward Stumpk 391 

The Montreal General Hospital-, its Organization, Hialorj' and Manage- 
ment, By W, F. Hamilton, M.D., CM 404 

The Kojal Victoria Hospital, Montreal. By Jno. J. Kubbon - . 415 
History and Description of the Kuoscvelt Hospital, By Jaubs K. 

Descfiptionof the Johns Hopkins Hoipital,BaltinioTe. Md. By IIksrv 
M. HURD, M. D 419 



CONTENTS. XI 

III. — Nursing of the Sick. 

Sick Nursing and Health Nursing. By Florence Nightingale . . . 444 

On Nursing. By the Hon. Mrs. Stuart Wortley 463 

Work done by Religious Communities devoted to the Relief of the 

Sick. By Cardinal Gibbons 470 

The Training of Male and Female Nurses in Catholic Orders. By Dr. 

KOllen 473 

The Work of Deaconesses in Germany 477 

The Victoria House for the Care of the Sick at Berlin. By LuiSE 

Fahrmann 480 

On Nursing in Scotland. By Rachel Frances Lumsden 487 

Les l^coles d'lnfirmi^res annexees aux Hdpitaux Civils de Paris. By 

Prop. Leon Le Fort 493 

La Source Normal Evangelical School for Independent Nurses for the 

Sick at Lausanne, Switzerland. By Dr. Charles Krapft 499 

History of American Training Schools. By Irene Sutliffs .... 508 
Proper Organization of Training Schools in America. By Louise Darchs, 513 

Discussion 523 

Trained Nurses as Superintendents of Hospitals. By E. P. Davis . . 526 
The Origin and Present Work of Queen Victoria's Jubilee Institute for 

Nurses. By Amy Hughes 531 

District Nursing. By C. E. M. Somerville 539 

On District Nursing. By Mrs. Dacre Craven, nSe Florence S. Lees . 547 

Discussion on District Nursing 554 

Nurses' Homes. By K. L. Lett , 557 

Discussion 561 

Mission Training Schools and Nursing. By Linda Richards .... 565 

Necessity of an American Nurses' Association. By Edith A. Draper, 569 

The Benefit! of Alumnae Associations. By Isabel McIsaac 573 

Discussion 576 

The Royal National Pension Fund for Nurses. By L. M. Gordon . . 578 

Obstetric Nursing. By Georgina Pope 584 

Midwifery as a Profession for Women. By Zepherina P. Smith, nie 

Veitch 592 

V Nursing of the Insane. By M. E. May 596 

Discussion 601 

The History of Workhouse Reform. By Louisa Twining 602 

The Instruction of the Sisters of the Red Cross. By Dr. M. Goering, 608 
Nursing in Homes, Private Hospitals and Sanitariums. By Mrs. S. M. 

Baker 611 

London Hospital Nurses' Home. By Eva C. E. LOckes 621 

Association for the Training of Attendants. By Mrs. D. H. Kinney, 624 

IV. — Dispensaries. 

Dispensaries Historically and Locally Considered. By Charles C. 

Savage 630 



XII CONTENTS. 

V. — First Aid to the Injured. 

Ueber Blutlose Operationen. By Dr. Friedrich von Esmarch . . 651 

Red Cross and First Aid Societies. * By Mr. John Furley 657 

First Aid to the Injured from the Army Standpoint. By Major Charles 

Smart, Surgeon, U. S. A 665 

First Aid to the Injured and How it should be Taught. By Henry G.. 

Beyer, M. D 676 

On the Organization in Paris of First Aid to the Wounded. By Alan 

Herbert, D. M., and W. Doxjolas Hogg, D. M 683 

The Ambulance System of New York City. By Geo. P. Ludlam . . 689 
An Improved Stretcher for Hospital, Ambulance and Military Use. By 

£. D. WORTHINGTON, M. D 693 

« 

VI. — Hospital Saturday and Sunday. 

Hospital Saturday and Sunday. By Frederick F. Cook 699 

Discussion 708 



ILLUSTRATIONS. 



HosFiTAi. FOK Contagious Diseases. 

Groand Plan 177 

Cross-section Plan 178 

Vertical Section of Garbage Furnace 180 

Cross and Longitudinal Sections of Cremation Furnace 181 

LAtTNDRY, University of Pennsylvania Hospital, Plan 204 

Naval Hospital, Haslae, Plan 223 

Naval Hospital, Malta, Plan 231 

Ground Plan of Naval Hospital, Yarmouth, Plate I 290 

Royal Naval Hospital, Yokohama, Plate II 290 

Naval Hospital at Kocheport, Plate III 290 

Naval Hospital, Toulon, Basement, Plate IV 290 

Naval Hospital, Toulon, Second Story, Plate V 290 

Naval Hospital at Brest, France, Plate VI 290 

H6PITAL Maritime de St. Mandrier, Plate VII 290 

Cherbourg Nouvel H6pital Maritime, Plate VIII 290 

U. S. N. Hospital at Portsmouth, N. H., Plate IX 290 

U. S. Hospital, Chelsea, Plate X 290 

U. S. N. Hospital, Brooklyn, Plate XI . 290 

U. S. N. Hospital at Philadelphia, Plate XII 290 

U. S. N. Hospital, Washington, Plate XIII 290 

U. S. N. Hospital, Norfolk, Plate XIV 290 

U. S. N. Hospital at Mare Island, Cal., Plate XV 290 

Plan of the U. S. Naval Hospital and Grounds, Yokohama, Japan, 

Plate XVI 290 

Design for Maternii'y Hospital for the University of Pennsyl- 
vania 330 

The Montreal General Hospital. 

Basement Plan 414 

Ground Floor Plan 414 

Second Floor Plan 414 

The Royal Victoria Hospital, Montreal. 

Administration Block, Medical and Surgical Wings 416 

Pathological Building, Floor Plans 416 



XIV ILLUSTRATIONS. 

Roosevelt Hospital. 

View from Northwest 42S 

View from Northeast 428 

Plot Plan of the Block 428 

Syms Operating Building 428 

Active Surgical Ward for Men 428 

Active Medical Ward for Men 428 

Surgical Ward for Children 428 

McLane Operating Room for the Gynaecological Service 428 

Syms Building. Inclined Plane leading to floor of Recovery Rooms . . 428 

Syms Operating Building. Main Amphitheatre 428 

Ambulance returning from a call 428 

The Johns Hopkins Hospital. 

Front View, Plate I 442 

Rear View, Plate II 442 

Block Plan, Plate III 442 

Heating Plans, Plate IV 442 

Octagon Ward, Plate V 442 

Octagon Ward, Interior, Plate VI 442 

Octagon Ward, Basement and Floor Plans, Plate VII 442 

Octagon Ward, Longitudinal and Transverse Section, Plate VIII . . . 442 

. Common Ward, Plate IX 442 

Common Ward, Interior, Plate X 442 

Common Ward, Main Floor, Plan and Sections, Plate XI 442 

Common Ward, Basement and Attic Floor Plans, Plate XII 442 

Common Ward, Longitudinal Section, North and South, Plate XIII . . 442 

Isolating Ward, Plate XIV 442 

Isolating Ward, Plans and Transverse Section, Plate XV 442 

Isolating Ward, Longitudinal Section, Plate XVI 442 

Gynaecological Laboratory, Plate XVII 442 

Gynaecological Operating Room, Plate XVIII 442 

Gynxcological Operating Room Plan, Plate XIX 442 

Improved Stretcher 694 



I. 

GENERAL SESSION. 



THE RELATIONS OF HOSPITALS TO PUBLIC HEALTH. 

By John S. Billings, M. D. 

Address as Chairman of the Section, 

The business of this Section relates to co-operative means for the 
care of those suffering from disease or injury, more especially of 
recent origin, excluding, for the most part, those forms of brain 
abnormity, or disease connected with what are known as insanity 
and idiocy, and also those forms of chronic and incurable disability 
which are not amenable to medical and surgical treatment. 

Primarily, hospital aid was intended and provided solely for the 
benefit of the poor — of those who were unable to obtain, at their own 
expense or by their own efforts, proper care in case of sickness ; but 
its field of work has been steadily extending ; it now has relations 
with the interests of almost every class of the community, and its 
results have greatly modified the methods of treatment of many 
forms of disease among the well-to-do classes as well as among the 
poor. 

It is largely by hospital organization and work that skilled phy- 
sicians, surgeons and nurses are provided for the public; and in the 
absence of hospitals, their proper and complete training is practically 
impossible. 

Each succeeding year more people resort to hospitals and dispen- 
saries for treatment, and this is especially the case in the United 
States. Forty years ago the number of hospital beds in our cities 
was very small in proportion to the population, when compared with 
the amount of such accommodation in the countries of Western 
Europe, and the demand for such accommodation was also small. 
People did not go to hospitals if they could help it ; it was believed 
that surgical operations and labor cases did not result so well in 
hospitals as they did in the homes of the people, even when these 



2 BILLINGS. 

homes were very small and not especially well ordered. Hos- 
pitals were for sick paupers, and we did not have many paupers in 
comparison with European countries. The war of 1861-65, and the 
great influx of immigrants, have produced many changes in public 
opinion upon these points. 

The war taught us how to build and manage hospitals, so as to 
greatly lessen the evils which had previously been connected with 
them, and it also made the great mass of the people familiar with the 
appearance of, and work in, hospitals, as they had never been before. 
Not only the tens of thousands of men who were treated in the great 
war hospitak in those days, but the hundreds of thousands of visitors, 
the parents, children, sisters and friends of these men, were thus 
educated, and they were educated not merely by what they saw and 
heard, but by what they did or tried to do to help make the 
patients more comfortable, by the work of the Sanitary and Christian 
Commissions, by the formation of local associations for giving aid 
and relief, and by becoming accustomed to the methods and results 
of voluntary co-operation in matters of this kind. 

Since the close of the war the formation of training schools for 
nurses in many of the large hospitals has been an additional means 
of interesting the public in the work, and of keeping it informed as 
to the progress made in securing the safety and comfort of the 
inmates. With the increase of knowledge about hospitals and their 
capabilities has come an increased demand upon them for accom- 
modation for persons in comfortable circumstances, who are affected 
with diseases which can be better treated in them than in private 
houses ; in other words, for private rooms for pay patients, especially 
those requiring surgical operations or suffering from certain forms 
of nervous diseases ; and from this class of persons and their friends 
the demand is now relatively greater in the United States than it is 
in Europe. 

During the last thirty years the demand for free beds in the public 
wards has also greatly increased, owing in part to a relative increase 
in the number of the very poor in our large cities, and in part to 
the immigration of large numbers of people accustomed in their 
former homes to seek public aid and hospital relief in case of sick- 
ness, and bringing with them this habit, which extends to others by 
force of example. 

The increase in free dispensary work, or out-patient relief, as it is 
sometimes called, has been even greater than that in free hospital 



THE RELATIONS OF HOSPITALS TO PUBLIC HEALTH. 3 

» 

beds, or in-patient relief, in our large cities, and the number of people 
who are not paupers who apply to these dispensaries for free treat- 
ment, although they are able to pay reasonable fees if required to do 
so, is becoming so large as to constitute a serious problem in hospital 
and dispensary management with us, as it does in London and other 
large European cities. 

As the health of a community depends on the health of the 
individuals who compose it, it is evident that there may be important 
relations between hospital aid in all its aspects and the public health, 
and it is to some of these relations that I desire briefly to call your, 
attention. 

The importance of hospitals for certain forms of contagious and 
infectious disease, as a means of preventing the spread of such 
diseases, would appear to be almost self-evident, yet very few 
cities in this country are provided with them. If there is a city 
" pest house," as it is commonly called, il is the relic of a smallpox 
outbreak, and is usually empty and uncared for, located in some 
desolate suburb, the grounds overgrown with weeds, and the build- 
ing itself corresponding in appearance to the ideas to which its name 
naturally gives rise. 

We have several papers before the Section on the subject of hos- 
pitals for infectious disease, and it is, therefore, unnecessary for me 
to say anything about the plans and arrangements for such institu- 
tions, which will, no doubt, be fully discussed in the Section meet- 
ings; but there is one point with regard to them to which I will 
briefly refer, namely, the question as to whether they should, or 
should not, be entirely free to all persons, no matter whether they 
are able to pay for the accommodation provided or not. It is urged 
by the majority of English health oflicers that the isolation of a case 
of infectious disease in a special hospital provided by the sanitary 
authorities for that purpose is not, in most cases, any special beneflt 
to or favor conferred upon the person so treated ; that it is done, 
and made compulsory, for the beneflt of the community and not of 
the individual, and that the community should, therefore, bear the 
cost. It.appears to me that this is true with regard to necessary 
cost, and to that only. It is not only permissible, but desirable, that 
such an hospital should be able to furnish a private room, a special 
nurse, and other extra accommodations, when demanded, as they 
would be if such hospitals were made use of by well-to-do people, 
and the party receiving such extra service and accommodation 
should pay for it. 



4 BILLINGS. 

To make such hospitals really useful in preventing the spread of 
disease there should be the least possible delay and formality in 
admitting cases. If a child affected with scarlet fever or diphtheria 
is brought to the door and the medical officer recognizes it to 
be such, it should be admitted at once, without waiting to send for 
a permit from some official, and the general rule should be that a 
certificate from any competent physician that the person is suffering 
from such a disease as the hospital is intended for should be a 
sufficient warrant for his admission. 

The increasing use of hospitals and free dispensaries to which I 
have referred is one of the signs of the socialistic tendency of the 
age, of the increasing tendency to subordinate the individual to the 
community in attempting to equalize the burdens and pleasures of 
mankind. If the process be carried a little further we might come 
to something like the scheme suggested by Mr. Havelock Ellis, in 
his recent book entided ^ T-he Nationalization of Health." This 
is to the effect that hospitals of the future are not to be charitable or 
voluntary institutions, but are all to be under national control, to be 
supplied from national funds, and to be free to every one. The 
country is to be covered with a network of such hospitals, each 
having a large medical staff, including ail sorts of specialists paid by 
the state. Private practitioners are no longer to be relied upon for 
medical attendance to the public ; it is supposed that they would 
only be consulted for minor and comparatively trivial ailments; the 
greater part of the work is to be done by medical officials. Private 
charity and individual philanthropy are no longer to be relied upon 
or encouraged ; the whole business is to be done by machinery ; 
health is to be equalized among the people. All hospitals are to be 
placed on the footing of hospitals for contagious diseases, and, with 
their medical staffs, are to become a part of a greater national bureau 
for the prevention of disease. As it is to the interest of a medical 
officer of the army and navy to prevent, as far as possible, the occur- 
rence of disease among the command to which he is assigned, in 
order that he may have as little as possible to do in the way of treat- 
ment, so it is supposed that these other medical officials will be 
active, zealous and efficient agents in prescribing and enforcing state 
and municipal sanitation. 

Two hundred and fifty years ago Sir Thomas Browne said that he 
counted this world not an inn but an hospital, a place not to live 
but to die in, and perhaps the plan I have outlined, when fully 



THE RELATIONS OF HOSPITALS TO PUBLIC HEALTH. 5 

carried out, will make many men of his way of thinking. I do not 
myself think that this scheme will be carried out, but the present 
tendency is in that direction ; hospital aid will be more and more 
resorted to in coming years ; there will be an increasing demand on 
the part of the constituted authorities, representing the majority of 
the people, for state or municipal supervision of what are at present 
private charities, upon grounds similar to those stated by Mr. Ellis, 
and it is important for us to recognize these facts and tendencies, 
whether we approve of them or not. I myself am of the opinion 
that hospitals supported by voluntary contributions confer quite 
as much benefit upon those who contribute the funds as upon 
those who are treated in them. If, however, there is to be public 
and official supervision of all free hospitals and dispensaries, should 
not these be in closer relation with and contribute more to the public 
health service of the cities in which they are placed than is the case 
at present? Even the city hospitals, those that are supported 
entirely by municipal funds, do not, as a rule, have any special con- 
nection with the city health departments, but are under entirely 
different management. They report the deaths which occur in them, 
and sometimes the cases of certain forms of contagious disease-which 
are treated in them, but little more. As to the voluntary hospitals 
and dispensaries that are supported from private funds, tl^ey make 
the same sort of reports and nothing more. But if my view of the 
tendencies of the age is correct, the time is not far distant when the 
health office of a city will have a daily record, not only of all deaths, 
but of all cases of disease treated free in any hospital or dispensary 
in the city, with specifications of name, age, sex, color, place of resi- 
dence, nature of disease and mode of final disposal. I need hardly 
comment on the value of such a record, both as an immediate emerg- 
ency guide for the health officer and as a basis for statistical investi- 
gation of the healthfulness of different parts of the city. 

I have already indicated the important relations to public health 
held by hospitals in their function of aiding in the training of physi- 
cians and nurses, and this is a point which should be constantly borne 
in mind in attempts to compare the efficiency and economy of differ- 
ent hospitals, or of the same hospital at different times. The teach- 
ing hospitals not only do the best work in the treatment of patients, 
who are more carefully examined and more scrupulously cared for in 
them than they are in non-teaching institutions, but they furnish the 
doctors and nurses required by the people in their own homes, and 



O BILLINGS. 

thf! quality of their work in this respect merits more scrutiny on 
thr part of the public than it has heretofore received. 

N(; doubt it would be a new idea to our mayors and municipal 
authorities if they were told that they are, to a considerable extent, 
rcfif)on»iblc for the quality of teaching and the standard for grad- 
uation in thoHe medical schools which obtain their facilities for 
clinical instruction in the hospitals supported by the city ; yet it is 
the truth, since they have it in their power to enforce almost any 
fitandard of medical education which they choose to favor. 

The tendency in this country is, however, towards the regulation 
of ntandardH of medical education by the state, and some curious 
(jnrntionii of jurisdiction will arise if a state should undertake to pre- 
Hcritic the conditions under which instruction in practical medicine 
Hiul numin^ shall be given in the hospitals of its several munici- 
palities. 

At present our best medical schools are desirous of having hospi- 
tals of their own, or at all events, hospitals in which they can control 
the appointments of the attending and resident medical staff, since, 
otherwise, the selection of some of their cliniail teachers may be 
made by those who have no interest in, or responsibility for, the 
work of the school. For the same reason the establishment of a 
lar^o gijncnil hospital by private endowment presents a strong 
inducement to the establishment of a medical school closely con- 
nected with it and under the same control ; in fact such an hospital 
without A medical school and nurses* training school is only doing a 
prtrt of the work which is rightfully expected and demanded of such 
AU insttitution. 

To a limitett extent this obligation to promote the pui)lichralth by 
ittcreasinR and diffusing knowledge as to the causes, nature and In^st 
methixis of prex^cntion or treatment of disease, rests also upon H|>r( jal 
hi>5pit;il5) including those for the insane, and no such hospiiJil «'iin Im 
Cvwj^idcrtxl as doing its complete and best work if it is \\o\ i imii iImh- 
ing to the training of physicians and nurses« 

With the pnwent rapid concentration of population in ritus*, ihr 
dcmaml for hospital accommodation will steadily inoieaso, und mi 
aK>win the dcnMind ^ municipal regulation of dwellinjjs in iIumi 
sanitair aspects ibr increase of tadliiies for limitinjj the :iprc\ul oi 
ivnt^ows and inlectious disease, and for skilled supervision oi lood 
5!wpplie&* All these thixigs are more or less coirelaied. and ihi y 
sho^ikl be «*udie<l t<^^then 



THE MEDICAL CHARITIES OF THE ENGLISH METROPOLIS. / 

It does not seem probable that any millennium will thus be pro- 
duced, or that nature's methods of eliminating the idle, the vicious 
and the unfit by diminishing birth-rates and increased death-rates 
will be either rendered unnecessary or done away with by advances 
in medicine or in sanitation ; but whether this be true or not, it is 
clearly the duty of those who have knowledge, means and oppor- 
tunities, to investigate these matters carefully, and to do all that 
they can to lessen the sufferings and sorrows of those who are unable 
to help themselves. 



THE MEDICAL CHARITIES OF THE ENGLISH 

METROPOLIS. 

By Lord Cathcart, a Member of the Lords' Committee.* 

Lord Bacon reminds us in his Chapter of Innovations, "It were 
well therefore that men in their innovations would follow the example 
of Time itself, which indeed innovateth greatly but quietly, and by 
degrees scarce to be perceived "; and that wise and witty Lord con- 
cludes with a reference to the Scripture; this passage so quoted shall 

^The Lords' Committee on Hospitals — The Order of Reference, Metropolitan 
Hospitals, &c. — Moved [April 28, 1890] That a Select Committee be appointed 
to inquire with regard to all hospitals and provident and other public dispen- 
saries and charitable institutions within the Metropolitan area, for the' care 
and treatment of the sick poor, which possess real property or invested per- 
sonal property, in the nature of endowment of a permanent or temporary 
nature ; and to receive, if the Committee think fit, evidence tendered by the 
authorities of voluntary institutions for like purposes or, with their consent, in 
relation to such institutions : And further, to inquire and report what amount 
of accommodation for the sick is provided by rate, and as to the management 
thereof; and that the witnesses before the said Select Committee be examined 
on oath ; agreed to (The Lord Sandhurst) : 

That the following Lords be named of the Committee : 

Lord Archbishop of Canterbury. Lord Saye and Sele. 

Earl Cadogan (Lord Privy Seal). Lord Clifford of Chudleigh. 

Earl Winchilsea and Nottingham. Lord Sandhurst. 

Earl Lauderdale. Lord Fermanagh (Earl Erne). 

Earl spencer. Lord Lamington. 

Earl Cathcart. Lord Sudley (Earl Arran), 

Earl Kimberly. Lord Monkswell. 

Lord Zouche of Haryngworth. Lord Thring. 




I 
I 

I 



be the keynote of that which, by your favor, is now to follow. The 
text runs thus : " That we make a stand upon the ancient way, and 
then look about us and discover what is the straight and right way, 
and so walk in it," ' 

The medical charities of the English metropolis, and in regard to 
them the House of Lords' inquiry and reports of the years 1S90, 
1891 and 189a, are the subject on which I have now the honor to 
address you : and craving your kind indulgence, I would premise 
that the limited time apportioned permits me to touch the fringe 
only of a vast subject, and my present essay must be considered 
merely as an introductory chapter or preface to three large official 
volumes' exhaustive of the subject, and which volumes, 1 confidently 
submit, would amply repay the study of that noble army of kindred 
professional and lay humanitarians on both sides of the Atlantic 
— generous rivals — whose benevolent labors in the truly Samaritan 
direction now in question excite our appreciation and admiration. 

It is truly British " to make a stand upon the ancient way and 
then look about us." In the heart of Old London, near which are 
situated the greater number of our Metropolitan Hospitals, a long 
succession of pregnant centuries seem spectrally to tumble over and 
jostle each other in the narrow streets — bygone centuries that have left 
many traces in the most busy and commercially frequented streets 
by ever-varying architecture — buildings, often like English laws and 
customs, the admirable constructions of our common ancestors. 
London, especially Old London, with crooked lanes and narrow 
alleys and beetle-browed houses, is nowhere spick and span and laid 
out symmetrically and mathematically in rectilinear blocks like Amer- 
ican cities, and notably like your own vast and beautiful Chicago. In 
Greater London we have also to deplore that there is a wide and 
darksome gulf to be bridged between west and east, between the 
mansions of the rich and the dwellings of the poor — that East End, 
much of which is a cheerless region where squalor and unloveliness 
walk hand-in-hand ; where, actuated by the passion of pity, kind 
hearts are exercised in the endeavor to bring to healthy lives sun- 
shine, change, variety, happiness: and where for the sick and 

'Jer. vi. 16. 

•Kepoits, vol- i.. Evidence, 1890. 51.; Vol. ii., Evidence, 1891, 6j. y-i 
Vol. iii., 1891, 2s. jd.. Summary. Conclusions, particulars ot every Metro- 
polilan Hospital in tabular form. Tliere is also an index analysis of the 
Evidence to accompany vol*, i. and ii., price 11. each index. 




THE MEDICAL CHARITIES OF THE ENGLISH METROPOLIS. 9 

injured poor the London Hpspital, as afterwards I shall have the 
pleasure of showing you, is very quietly doing a very grand and 
greatly appreciated work. 

Of the London hospitals generally it may be said, with apparently 
inadequate structures and means, great and truly admirable work is 
being done. And praise be to God, this noble work is alike Jew and 
Gentile : no regard is had to either race or creed, the only qualifica- 
tions being but too apparent — namely, medical need, necessity, and 
adversity. 

We, indeed, in old England " make a stand upon the ancient 
way ** : the London hospitals originate in monastic charity. St. 
Bartholomew's, the greatest of the English medical charitable insti- 
tutions, was founded a. d. 1183 by Rahere, who also founded the 
adjacent Priory of the same name : the hospital, nominally under 
the Priory, was from the first virtually independent — not an alms- 
house, but a hospital for the sick. William Harvey, a small man 
with black hair, the immortal author of '' Exercitatio de Motu Cordis 
et Sanguinis," a record of the greatest of the discoveries of physi- 
ology, was physician here for thirty-four years, 1609-1643. Some 
rules drawn up by him are to this day in full force : amongst other 
things his charge recites, ** You shall prescribe such medicines only 
as should doe the poor good without regard to the pecuniary inter- 
ests of the apothecary." St. Thomas's Hospital was originally founded 
in 1213 by the Prior of Bermondsey as an almonry; purchased at 
the Reformation by the City of London, it was converted into a 
hospital for the sick; rebuilt in 187 1 in seven blocks, it was consid- 
ered the model hospital for the world, until you, in generous rivalry, 
constructed your still more perfect Johns Hopkins Hospital at Balti- 
more. One word more on this curious subject of historical origins ; 
the* Lock Hospital for venereal diseases — perhaps, having regard to 
the welfare of the general population, the most important of the 
London special hospitals — derives its name from the French 
**loques " = rags, lint applied to sores; it was originally and from 
very early times a lazar-house, a spital for leprous people, known in 
1437 as " Le Lokes." * 

The Lords' inquiry was instituted in consequence of a most influ- 
entially signed petition, amongst others signed by sixteen hundred 
representative London medical men, 35 per cent of the medical 

' See London, Past and Present, 3 vols. Wheatley and Cunningham. 
London: John Murray. 1891. 



lO CATHCART. 

profession of the Metropolis. The concluding paragraph of the peti- 
tion runs thus : '* Your petitioners, for reasons set forth at length, 
pray your right honorable House to appoint a Select Committee to 
make inquiry in regard to the financial and general management and 
the common organization of medical institutions, endowed and vol- 
untary, and in regard to the administration of poor-law institutions 
for the aid of the sick in the Metropolis, and to make recommenda- 
tions." 

On the motion of Lord Sandhurst, a Select Committee of fifteen 
was appointed on April 28, 1890 — "a strong committee"; that is to 
say, a committee largely composed of experts or of persons having 
wide experience in the conduct of affairs. Such committees have 
plenary powers to call for all persons and papers, the evidence is 
taken on oath, witnesses are examined and re-examined — virtually 
cross-examined — to any extent that may appear necessary; and — 
this is most important in any inquiry — the witnesses, however out- 
spoken, are by privilege absolutely safeguarded. 

Lord Sandhurst was throughout in the chair of the committee, 
and he was the mainspring of the whole inquiry. A man in the 
prime of life, subject as fully as any one to all the distractions of 
business and society, I may mention him as an example of the devo- 
tion evinced by laymen in the working of our medical charities. 
As chairman of the Middlesex Hospital, I believe, when the political 
party to which he is attached is not in power, and he is consequently 
free from official duty, he visits the charitable institution he admir- 
ably administers almost every day of every week. 

In the several reports of the committee, full and most detailed 
information is virtually given either by reported parole evidence, or 
by schedules of queries with replies in regard to every institution in 
" Greater London " for the relief of the sick poor. These institutions 
are (i) charitable, and (2) provided under the poor-law. They may 
further be classified as follows : ^ 

General hospitals, with and without schools. 

Special hospitals. 

Dispensaries, provident, part pay, charitable, and poor-law. 

Poor-law infirmaries, and 

Hospitals for infectious cases under the Metropolitan Asylums 
Board. 

Roughly estimated, at the commencement of the inquiry the com- 
mittee was to contemplate some 24,000 beds, with 122,000 in-patients 



THE MEDICAL CHARITIES OF THE ENGLISH METROPOLIS. II 

to occupy them for one year, the out-patients treated during that 
period being 1,585,381.* 

Of old, a witch's prayer was said to be read backwards — a course 
in such case perhaps . objectionable enough, but as regards the hos- 
pital committee reports, I venture to recommend this method of evil 
origin as the most convenient, and with your permission in my 
further, observations I propose to follow it. Namely, read the gen- 
eral conclusions of the committee, in vol. iii. ; then where most inter- 
ested refer back to the summary of evidence, which in turn will refer 
the reader retrogressively to the evidence given in exienso in the 
first and second volumes. I propose to myself, then, in this paper 
to follow henceforth this simple and, I hope, exact method — namely, 
to run rapidly through the conclusions arrived at and recommenda- 
tions made by the committee, and which, so far as they go, have my 
full concurrence ; condensing these conclusions as honestly as I can 
under the various heads; and afterwards under these respective 
heads giving you in a friendly manner and concise form my own 
candid impressions and views on those salient and practical points 
which I think will most interest my practical and experienced audi- 
ence. 

Endowed Hospitals. 

The three great endowed hospitals, St. Bartholomew's, St. 
Thomas's, and Guy's, might have an improved system of manage- 
ment; regret is expressed by the committee that in St. Thomas's 
and Guy's, from want of funds, some beds are vacant and others let. 

On this I need only observe that, amongst others, the late Dr. 
Steele, of Guy's, an excellent and most experienced witness, told the 
committee that all hospitals are best administered by weekly boards 
— this system so strengthens the hands of the immediate hospital 
authority. The drainage of St. Bartholomew's was found by the 
committee to be very defective. As a consequence, I am glad to see 
by the newspapers, this crying evil has been remedied by reconstruc- 
tion at a cost of some 16,000/. Here is the last account of a year's 
work at St. Bartholomew's : 

5953 in-patients, 16,143 out-patients, ^^^ 142,745 casualty patients, 
were treated there during last year. In addition 1775 women were 
attended in confinement, of whom 6 died. The total number of 
children born was 1802, including 60 twins. During the year a 
large number of patients were relieved from the Samaritan Fund on 

* See Appendix to this paper. 



12 CATHCART. 

their discharge from the hospital, and 936 patients were sent to con- 
valescent homes. 

Much that I have to say under other heads will equally apply to 
the endowed hospitals; so, with the observation that the most 
economical administration is often the most efficient administration, 
and that, in my opinion, it is wonderful how institutions living from 
hand to mouth hold their own with those largely endowed, I pass on 
to consider the 

General Hospitals, 

The committee observes that the eight general hospitals with 
medical schools, supported virtually by voluntary contributions, are, 
according to the evidence, well administered on a nearly uniform 
system. Individuality should be maintained ; generous rivalry tends 
to medical and administrative efficiency. The committee desires to 
remove exclusive London diploma restrictions, and would throw 
open hospital appointments, as at St. Mary's Hospital, to all suitable 
graduates. There appears to be an omission in the conclusions of 
the committee which I do not think was intended, for eight general 
hospitals without schools are worthy of honorable mention. The 
committee notes the enormous amount of work carefully done by 
unpaid boards of managers. 

I now proceed to give you my own views, which naturally fall 
under these heads : A few general observations ; the patient, the 
public, and the practitioner ; ending by an example — a little sketch of 
the poor, very poor districts effectually ministered to by the London 
Hospital. 

A general hospital with us takes all manner of diseases except 
certain highly infectious complaints which are treated in the rate- 
supported asylums. Proper hospital work was well defined in the 
evidence ; it is to lodge and cure or relieve bad and necessitous cases. 
These general hospitals are characterized by kindness to the living 
and decent reverence for the dead; on this latter point especially, the 
kindness to the living being obvious, we made strict inquiry. Entire 
publicity is happily of the essence of our voluntary hospital system ; 
that publicity, in my opinion, is sadly wanting in the rate-supported 
infirmaries. I am justified in thinking they could not stand the test 
voluntary hospitals are submitted to, for it is in the interest of sub- 
scribers and others to see that their money is well spent. It is an 
axiom, then, that the officers of institutions which exist by the charity 
of the public should have nothing to conceal. It were well to ponder 



THE MEDICAL CHARITIES OF THE ENGLISH METROPOLIS. 1 3 

over the following suggestive observation : no conceivable Govern- 
ment could undertake for a day the commissariat of our vast English 
metropolis; any such attempt to feed and othetVise supply from 
four to five millions of people would utterly break down. So in 
regard to the proportionate sick : only the free co-operation of the 
voluntary and rate-supported hospitals can hopefully undertake to 
cover, even inadequately, the vast and daily increasing field for hos- 
pital requirements that opens out before us. 

That patients come faster — much faster — than money is the uni- 
versal experience. Very humble, very poor persons find their way 
into the voluntary hospitals, but lower depths are still dredged for 
the poor-law infirmaries. I fear in the nature of things, moribund 
cases in London stand a bad chance or no chance of being taken 
into a voluntary hospital (please bear in mind my previous definition 
— proper hospital work is to " cure or relieve "; Dr. Steele, of Guy's, 
estimated that two- thirds of the patients came from the neighborhood 
of the hospital). In most hospitals, mercifully, anaesthetics are admin- 
istered outside the operating theater. The very cleverly managed 
Charing Cross Hospital has a reception ward always ready for accidents, 
so that the general wards during the night are undisturbed. There is 
also in that hospital a well-arranged mortuary chapel — a thoughtful 
gift — into which bodies are removed from the dead-house when the 
friends of the deceased visit the hospital. In every case we found 
very proper arrangements were made in relation to the dead, and 
every consideration shown for the feelings of their friends. Patients 
as a rule are very grateful, and nurses are often worried by the 
grateful tender of unacceptable and unpermitted little presents. The 
patients have no objection to clinical instruction ; their sense of self- 
importance is gratified by notice and publicity. A patient, it is said, 
has four values: as a worker he is valuable to the community ; he is 
necessary for purposes of medical instruction ; as a case he is pro- 
fessionally interesting ; and should a well-to-do patient be improp- 
erly admitted to the hospital, the general practitioner is interested 
by reason of the loss of possible fees. The immediate problem is 
how to harmonize these various interests. Again and again this 
essential question will arise, and will continue to arise. How to 
limit voluntary hospital charity to the worthy — that is <o say, to the 
indigent ? 

Public opinion, with us, no doubt desires to reform hospital admin- 
istration and adjust the claims of poverty, so that the charities shall 
not foster pauperism ; of this more hereafter when we reach the out- 



14 CATHCART. 

patient department. Meanwhile it may be well to note certain facts 
pretty well established by the evidence. 

High authoritfes who have studied abroad, and compared home 
with foreign institutions, are not in favor, as a general system, of 
State-paid hospitals. In all voluntary hospitals there should be, 
under the weekly board, a resident official, with full authority. It 
is desirable to maintain a chain of responsibility, avoiding anything 
like divided authority ; I think I heard even the phrase " a benevo- 
lent despotism." The sanitary zone is important — that is, an aerial 
space all round each hospital, which with us does not invariably exist. 

The difference between beds and occupied beds is 25 per cent. ; 
apart from beds vacant from want of funds or patients, there must be 
a working margin of from 10 to 12 per cent. In any great emergency 
I should fear a breakdown in our voluntary system ; working under 
extreme high pressure, there must be overcrowding — necessity 
knows no law. Miss Nightingale * goes fully into the question of the 
space per bed on the plan required for efficient nursing. The Mid- 
dlesex, an old building, has 88 square feet per bed ; St. George^s, 
69 square feet ; the new St. Thomas's has 112, which is considered 
sufficient. Teak, or hard wood floors, dry rubbed and polished, are 
everywhere being substituted for deal planking and wet swabbing. 

Sanitation and Listerism have wonderfully reduced hospital mor- 
tality ; public opinion should insist on a plan of the hospital drains 
kept up to date and exposed to public view. Fire arrangements 
should be studied and concerted with the admirable Metropolitan 
Fire Brigade. There is usually a properly constructed furnace for 
the cremation of such nasty things as cannot be taken by the drains. 
Newspaper reporters should be invited and encouraged to attend all 
general meetings. 

The Samaritan funds are kept separately, and usually well admin- 
istered. St. George's Hospital is a good example of management in 
this respect; even the families of patients are sometimes visited and 
helped. In all hospitals it is frequently necessary to burn the whole 
of the clothes of a patient, and consequently on discharge a new 
fit-out must be provided. In some hospitals the friends of the 
patients are expected to provide or pay for tea, sugar and butter ; 
but where, owing to extreme poverty, this is impossible there is 
usually a supply from the Samaritan fund. One general hospital, 
with 179 occupied beds, calculated that for all the patients a free 

' Report^ vol. i. p. 607. " On the Nursing Service of Hospitals." 



THE MEDICAL CHARITIES OF THE ENGLISH METROPOLIS. 1$ 

supply of tea, sugar and butter would cost 400/. a year. I always 
ask in a hospital to taste the beef tea ; its quality is not a bad test of 
management. 

The question was constantly asked of hospital authorities, what do 
you do in infectious cases, such as smallpox and scarlet fever? and the 
constant reply was — " Wire for an ambulance and it comes at once." 
This is the latest account of the ambulance service in London : At a 
' meeting of the Sanitary Inspectors* Association, it was explained that 
there were two principal voluntary services — namely, the St. John^s 
Ambulance Association and the Hospitals Association. With respect 
to the first, the system of training men and women had been extended 
throughout the kingdom, and, indeed, over many parts of the world. 
Members were deputed to go on ambulance duty on public occasions 
like the Lord Mayor's Show. In 1891 the associations were sup- 
ported by donations and subscriptions to the extent of 4000/., by 
sales of shares 8000/., fees for removal of patients by the invalid 
transport corps about 1500/., or a total income of about 13,500/. The 
annual expenditure was about 10,500/. The association had recently 
established an invaXd transport corps for the convenience of sick and 
injured persons (infectious cases excepted). 

The Hospitals Association had proved a valuable adjunct to the 
ambulance system. By that association 2101 cases had been 
removed in three years. The Metropolitan Asylums Board's 
removals by ambulance had doubled those of any previous year, the 
number being about 32,000.' 

We now come to the hospital medical officer. 

This comprehensive question was asked : In regard to what has 
been called martyrdom of hospital appointments it is argued that you 
eminent medical men have used these general hospital appointments 
as a ladder by which to climb to fame, and that thereby you derive 
benefit, and that if any eminent man wants to give up his hospital 
appointment there are six other eminent medical men ready to take 
that appointment? Answer. — That is quite probable. 

Quesiion. — And that to a large extent is the view of your pro- 
fession ? Answer, — That is quite probable. 

Notwithstanding, say I, all honor to the army of professional men 
who so nobly bear the heat and burden of the day. Medical educa- 
tional interests must to some extent militate against the reform of 
hospital abuse by well-to-do patients ; necessarily medical men are 
more interested in cases than in the social fitness of the patients. 

* The Timest April 10, 1893. 



1 6 CATHCART. 

The London Hospital is in the midst of the poor and for the poor 
— the docks, the river side, Spitalfields, and other very poor districts 
— purely and simply the poor man's hospital. The expenditure last 
year was 60,000/. 10,070 in-patients and nearly 113,000 out-patients 
were treated during the year. The nursing staff is 250. Go there on 
visiting day — say Sunday afternoon — you find it swarming with 
visitors ; little satisfied groups round most of the beds. There is no 
question at all — these visitors in fustian and frieze are socially of the 
right sort — they believe in this hospital, of which they are very 
proud. Applying the same test in the West-end of London, I con- 
fess I have had my misgivings; patients in shirts and shifts are 
much alike, but not so the friends — broadcloth and silk, top hats 
and gum-flower bonnets are in such cases sad tell-tales, suggesting 
now and then even a bank account and a check-book. Hear the 
late Mr. Montagu Williams, Q. C.,* magistrate of Worship Street and 
Thames Police Courts, well and honorably known as the ** Poor Man's 
Magistrate"; his impressions are quite consistent with the evidence 
taken by the Lords' committee. The London Hospital, says Mr. 
Williams, is full of variety — sl greater variety of people than in any 
other — a mass of suffering humanity representing nearly every 
nationality on earth. There is not another hospital in England — 
not in the world — so well conducted. I have visited at all hours to 
take dying depositions and for other objects, and consequently I am 
well able to judge. Seven hundred and seventy -six beds can be made 
up. Two wards are endowed for Jews, with separate kitchens and 
cooks, kosher meat and unleavened bread ; the Passover is celebrated 
and all Jewish rites are strictly observed. The nurses are Christians, 
and the often Yiddish-speaking patients, with wonderful powers of 
dumb-show, will take medicine from no other hands ; but the Chris- 
tian nurses dare not touch the dead — so soon as the breath of life 
flutters to depart there instantly appears the Jewish " watcher." The 
nurses as a body, says Mr. Montagu Williams, are amiable, patient, 
and gentle. In the London Hospital we have an admirable example 
of the maximum of good and efficient work effected with a minimum 
of expenditure. 

Convalescent Homes. 

The committee says the accommodation for convalescents in 
detached homes and otherwise is deficient ; this causes one or other 
of two evils— premature discharge or hospital congestion; besides, 

. ' Round London. London : 1892. 



THE MEDICAL CHARITIES OF THE ENGLISH METROPOLIS. 1/ 

patients would often recover more rapidly if sent into the country. 
To this I have only to add that we were told the patients much 
prefer the seaside. 

Out-patients. 

On the questions of out-patients and dispensaries, much evidence 
was taken by the committee. The out-patients' departments are 
open day and night for the relief of the poor; as regards medical 
education they are of essential importance. They are available, and 
private medical practitioners, whilst retaining their patient, should 
more fully avail themselves of out-patient departments for consult- 
ative purposes. These charities are not abused to any serious extent. 
When doubt arises, a patient should be called upon to establish a- 
primd facie case for charitable relief. Each out-patient attends on 
the average about three times. The committee do not attach undue 
importance to statements as to the reduction, owing to the unpaid 
work of the hospitals, of the fees of medical practitioners. It is 
obvious there must be some tendencey in that direction. But in 
London; with its heterogeneous and migratory population, there are 
above the pauper line very many persons who, owing to continued 
illness, a numerous family, or otherwise, are quite unable to pay for 
medical assistance. 

Upon this I beg you to observe that there are out-patients and 
out-patients; in other words, there is invariably a sifting process, 
and the trifling and more numerous cases are called casuals, cut 
fingers and that sort of thing, which are attended to once for all. 

Out-patients in their original inception naturally arose from in- 
patients, and to relieve hospital congestion — " You may go home, 
but let us see you occasionally ; we should be glad to know how you 
get on **; or, " Your wound will require to be dressed every second 
day "; and so on — this is the little seed which has produced an 
enormous tree. Some hospitals limit new cases to fifteen medical 
and fifteen surgical patients a day, but even then hard cases are 
allowed to make bad law. Often — too often — the medical man 
administering an out-patient department sees it is not medicine that 
is wanted but a basin of soup. 

Sir Andrew Clark, the President of the College of Physicians, 
every word of whose evidence should be carefully studied, for it is 
a^ weighty in substance as it is admirable in style, told the com- 
mittee ** that to close the out-patient departments of the hospitals 



IS CATHCART. 

would be the greatest public calamity, and disastrous to the art of 
medicine." After an eloquent account of how medicine is or should 
be taught, Sir Andrew added: " In the hospital wards disease is seen 
in its later stages, in the out-patient department in ils inception." Sir 
Andrew said, as his own experience at the London Hospital, he 
could, in ihe out-patient department, see three or four hundred people 
in an afternoon. 

Overlapping is where a patient may go from place to place, from 
voluniary to poor-law institutions, or otherwise — say, for example, 
for some particular treatment or appliance; there was evidence in 
regard to this evil against which it is ditlicuk to guard. 

The medical profession, like other learned professions, is over- 
'stocked; and in London competition is probably much more severe 
between medical men and medical men than between medical men 
and the out-patient departments of the voluntary medical charities. 
Private adventure dispensaries, for example, are set up in poor dis- 
tricts; say an altogether unscrupulous qualified medical man runs 
several of these dispensaries under cover of his own name, and 
employs unqualified assistants; medical fees in that district are 
immediately reduced almost to a vanishing-point. An out-patient 
department, however, well managed, is a social test in itself; crowds, 
long wails, unpleasant neighbors, crying and irritating children. 
There is also some little risk of looking in with one complaint and 
coming out again with another. 

No man in England is so high an authority on the condition of the 
people of East London as Mr. Charles Booth ; his arbitrary division 
of the people is "poor" and "very poor." " By 'poor,'" he says, "I 
mean a bare income, such as iSs. to 20s. for a moderate family ; by 
'very poor,' those who fall below this standard. With my 'poor' 
it is a struggle, while the 'very poor' live in a slate of chronic 
want." The evidence taken by the commiltee shows the wage limit 
alone Is as a test absolutely fallacious ; this limit is an element only 
in the general consideration of a case for voluntary medical relief. 

Is voluntary medical relief a first step to pauperism ? — this crucial 
question now stares us in the face. This question, like many others, 
must be answered relatively. No doubt forty years ago there was a 
very strong and honorable feeling of independence in the country, 
and which largely, but in lesser degree, prevailed in the town — a 
feeling well expressed by the poet:' 

' Hood. 



THE MEDICAL CHARITIES OF THE ENGLISH METROPOLIS. I9 

No parish money, or ]oaf, 

No pauper badges for me ; 
A son of the soil, by right of toil, 

Entitled to my fee. 
No alms I ask — give me my task ; 

Here are the arm, the leg, 
The strength, the sinews of a man. 

To work and not to beg. 

This once fine rural population, by agricultural distress, is now more 
and more driven in upon the towns to further congest already exist- 
ing congestion. Modern legislation — I state facts, I do not desire to 
question policy, but to state facts, when I say that our legislation has 
tended and tends to rub off sensibilities; the receipt of poor-law 
medical relief does not disqualify for the parliamentary franchise, 
elementary education is free, we propose to limit the hours of adult 
labor ; again, we have the slavery of trade unions — ^^abnormal up- 
heavals of unskilled labor — starving strong men with their pockets 
full of pawn-tickets reluctantly fighting for weeks for an intangible 
punctilio, and they themselves with their wives and children rattling 
begging boxes under everybody's nose. When I consider all these 
and other like things in their due proportions and relations, I am not 
of opinion that appreciably voluntary medical charity with us is a 
first step towards pauperizing the community. 

The Distribution of Hospitals^ 

in the opinion of the committee, is no doubt faulty ; this is owing to 
the extraordinary growth of the population. On this I need only 
observe that the poor dislike dislocation and separation from their 
friends, but a poor man will often pass several hospitals to reach one 
for which, for some reason or another, he has a preference. 

Medical Education^ 

in the opinion of the committee, would be promoted by the affiliation 
of the London medical schools to a teaching university. The pres- 
ence of students in the poor-law infirmaries would be stimulating as 
regards the medical officers by reason of the observation and criti- 
cism which is brought to bear on diagnosis and treatment. 

It is of the essence of clinical teaching that where the beds are, there 
are the professors and students gathered together. The entrance 
examination of the medical student is of great importance ; he should 
be well grounded in ordinary knowledge. Under a very recent 



I 



20 CATHCART. 

regulation, students before registration may now present themselves 
for examination in chemistry, physics and biology. Mr. Pickwick*s 
friends, the " Bob Sawyer," " Ben Allen," and " Jack Hopkins" types 
of medical student, are happily extinct; all the deans of schools 
reported the conduct of the students of our day as exemplary. Many 
of the hospitals have a students* club, a valuable institution, which 
keeps the young men together, and where they can dine and pags 
their spare time in a homely and comfortable manner. Medical 
students now do not "walk the hospitals" only; they render very 
valuable and most devoted and charitable services. I should 
like to say a great deal about the clever young medical ladies, 
but must refer the curious to the reports of the evidence. Suffice it 
to say they are honorably mentioned ; they are not any of them 
frightened by the sight of blood, and they are not predisposed to 
think of love when it is their duty to diagnose or to dispense. Mrs. 
Blackwell, M. D., of New York, was the first medical woman to reg- 
ister in England; this was in 1858; following Mrs. Blackwell came 
Miss Garrett, now Mrs. Garrett Anderson. Medically-disposed 
ladies could not do better than refer to the ample evidence with 
which Mrs. Garrett Anderson, M. D., favored their lordships; 
Dean of the London Medical School for Women, this eminent 
lady is with us the recognized head of the female branch of her 
profession. There are now forty-five medical women practitioners 
in London. 

Special Hospitals. 

The committee concludes, as to their use and abuse, that the 
marked hostility of the medical profession in regard to them arises 
from the fact that numerous small hospitals have been instituted by 
certain medical men, with a view only to their own advancement, 
leading to waste of money and the deception of the public. There 
are, however, exceptions; for instance, hospitals for children and the 
Lock hospitals have special claims for favorable consideration. 
Lock cases, owing to the character of the diseases (venereal) and the 
patients, should be separately treated. Patients in a highly conta- 
gious condition discharge themselves on such occasions as race 
meetings ; there should be a power of detention. 

I would observe that honorable mention should be made, amongst 
others, of the Seaman's Hospital, late the good ship ** Dreadnought"; 
this institution down the river is exactly what its name implies, and 



THE MEDICAL CHARITIES OF THE ENGLISH METROPOLIS. 21 

is simply invaluable. These special hospitals, which in their nature 
and by comparison are very costly, have been called private-adventure 
hospitals, but the term is resented by some specialists ; the public 
little recognize how ^medicine is now specialized. The committee 
was told, as an argument in favor of special hospitals, that it was to 
the Samaritan Hospital we owe the opportunities given to Sir 
Spencer Wells of doing work which throughout the world is famous ; 
it was said at that time by a surgeon of a general hospital, in regard 
to these now common abdominal operations, that failure, followed by 
death, deserved to be treated as manslaughter. It is noteworthy 
that special hospitals are largely supported by wealthy persons who, 
in a medical sense, have specially suffered ; specialty is, of course, 
Adam Smith's division of labor, but the general hospitals now have 
special wards. 

Cordially concurring as I do with the general conclusions arrived 
at by my colleagues, I feel it my duty now to entreat more especial 
attention to the evidence in extenso given in regard to Lock dis- 
eases. You will please bear in mind that in England the late Con- 
tagious Diseases Act and its repeal, and the policy or otherwise of 
that repeal, is still a burning political or religio-political question. I 
append my own conclusions on the subject, premising that no value 
should be attributed to my view except in so far as it is consistent 
with and duly reflects the evidence. 

The Lock Hospital, as regards the general welfare of the popula- 
tion, is undoubtedly the most important of all the special hospitals, 
and yet it lives from hand to mouth, and even now is in debt. The 
London Hospital and St. Bartholomew's have Lock wards ; separa- 
tion is obviously essential in these highly contagious and most offen- 
sive primary Lock cases. There is, without question, in the medical 
charities of London, a disposition to minimfze the treatment of these 
cases; the Lock Hospital receives Lock cases from most of the 
general hospitals, as well as from workhouse infirmaries. The out- 
patient department of the Lock Hospital does valuable work which, in 
a pecuniary sense, is by the male out-patients themselves gratefully 
and tangibly acknowledged. Gummatous disease, a tertiary and 
non-contagious condition, somewhat similar to cancerous disease, 
may be found in all the general hospitals; many young persons 
suffering from allied and inherited skin and other affections which, 
until recent years, were not recognized as of syphilitic origin, are 
also treated in the general hospitals and elsewhere. Numerous 



22 CATHCART. 

infantile and congenital cases are usually relegated to the hospitals 
for children. There is, unquestionably, amongst the general popula- 
tion, a considerable syphilitic taint. It is in evidence that on occa- 
sions such as the Derby race week, abandoned women in a highly 
contagious condition not only discharge themselves from the Lock 
Hospital, but they induce other women in a like condition to leave 
with them. Taking all the female patients, 31 per cent, and of 
prostitutes 43 per cent, leave the hospital in a condition to spread 
contagion ; the question of detention naturally arises, but unless the 
Contagious Diseases Acts were in some form revived, detention in a 
voluntary hospital would tend to discourage and deter applicants for 
treatment; one witness well observed, **We are a hospital, not a 
prison.'* The evidence shows the existence of an actuating feeling 
that in Lock cases the sinner should suffer for the sin, and that such 
cases are not fit objects for public charity; enlightenment and 
self-interest, not to speak of humanity, should dispel any such 
mistaken notion; not only are virtuous women, innocent children, 
and unborn babes frequently victims, but the physical welfare of the 
whole population of the country is more or less involved. In the 
words of the secretary, words which are almost pathetic, " It is 
obvious on the face of it that the Lock Hospital is such a difficult 
charity to beg for." 

That excellent English medical paper the " Lancet," I found a 
valuable and trustworthy assistant during the whole of the inquiry. 
A leading article * well treated the Lock question in the sense I have 
endeavored to suggest ; it pointed to the importance of such cases 
as objects for study. Harlots, it is said, should not be left to suffer 
and infect ; a man eaten up with syphilis is certainly an object of 
charity; and lastly attention was called to the Great Exemplar, 
strangely forgotten during a heated controversy ; — the Great Phy- 
sician ** healed all manner of sickness and all manner of disease." 

The medical superintendent of Marylebone Infirmary answered 
thus:' 

Question, — These poor wretched people (suffering from venereal 
disease) simply rot at home in their own dens? 

Ans7e/er, — They do rot — it is quite a true expression. I had a 
man the other day who had not had anybody by him for a fortnight, 
a mass of sores ; he was found out by a policeman. The Lock 
refuge for women, crippled as it is for want of funds, is the blessed 

* July S, 1890. 5 Report, vol. ii., p. 642. 



THE MEDICAL CHARITIES OF THE ENGLISH METROPOLIS. 23 

means of rescuing and socially restoring many an unfortunate^ there 
is always with us the " one more unfortunate ! " 

Oh I it was pitiful ! 
In a whole city full, 
Home she had none. 

Hospital Accounts, 

The conclusions of the committee refer to the important matter of 
the desirable uniformity of hospital accounts, the object being, for 
purposes of comparison, a reliable estimate of the cost per bed. A 
mass of interesting evidence bearing on this subject was taken, and 
every probability now points to a satisfactory understanding for 
common action. 

I wish to call attention to the appendix of the third Report of the 
committee. There will be found at length the ** Index of Classifica- 
tion," on which uniformity of system must greatly hinge ; with this 
index before him each hospital accountant can without difficulty 
dissect, post, and narrate uniformly. The cost per bed as the unit is 
of course the best standard of comparison. To arrive at the actual 
cost per bed there must be as well a common understanding as to 
the deduction to be made on account of each out-patient — it would 
be costly to keep a separate out-patient dispensary account. A 
complete system is now being worked out by a committee of hospital 
secretaries; dating from 1872, the original conception of this excel- 
lent system is due to one who has done so much for the hospitals of 
the world, to Mr. Henry C. Burdett. 

In regard to uniformity of accounts, and the essential importance 
of that uniformity, the sum of the whole matter is that everything on 
earth is relative, and all criticism depends on comparison. 

Nursing. 

The subject of hospital nursing mentioned in the conclusions of 
the committee is very fully dealt with in the evidence reported. The 
committee note with satisfaction that the health of the nurses in 
London is good. The thorough training of a nurse should occupy 
at least three years. 

I dare not rush in where angels might fear to tread; that is to say, 
the evidence taken in regard to the nurses and nursing is exhaustive 
— it is too voluminous to be treated adequately in this paper. I 
venture consequently, referring to the Reports, to indicate only its 
general tendency. The general position of the hospital nurse has 



24 CATHCART. 

been greatly improved of late years, and that improvement is pro- 
gressive — better messing, where possible, comfortable single rooms 
apart from the wards;' more holidays and hours off duty, and consid- 
eration duly given to pay and superannuation. 

I have had the pleasure of making the personal acquaintance of 
many of the very able matrons of the great London hospitals, and, 
knowing them, I am not at all surprised that under such guidance 
the hospital nursing generally should be excellent. These ladies 
rejoice in their time-honored title of matron= mother, which exactly 
describes what their position is and should be. The matrons, or 
some of them, deprecated the use of such pretentious and misleading 
appellations as " lady superior" and " lady superintendent." 

Miss Florence Nightingale is the founder of our nursing system, 
and with reverence I always picture her to myself as a saint with a 
nimbus. She found the " Sairey Gamp and Betsey Prig " school of 
nursing, and replaced that old effete school with active, trained, 
cheerful, two-steps-at-a-time-up-a-stairway young women. Miss 
Nightingale's ** Suggestions for improving the nursing service of 
hospitals, and the method of training nurses for the sick poor," will 
be found in the first volume of the Report, p. 602. 

An interesting paper on nurses, by Mr. Burdett, will also be found 
in the second Report of the committee, p. 808. 

Miss Isla Stewart, matron of St. Bartholomew's Hospital, wrote* 
a paper on hospital nursing, from which, fully recognizing the justice 
of her observations, I now cite. The '* jninistering angel " point of 
view is imaginary; there is no more self-sacrifice in a hospital than 
out of it. The nurses are not pale-faced, pious, and overworked, 
but a merry set of hard-working women, who eat, sleep, and enjoy 
with zest any pleasure that comes in their way. They gossip and 
grumble, but are kindly, being generally intelligent, yet rarely intel- 
lectual. Towards the world the nurse is a woman desiring indepen- 
dence ; towards the hospital her relations are purely commercial ; 
towards the patients the nurse is a paid attendant, bound to jsittend 
to their comfort and well-doing. Sentiment, often the salt of exist- 
ence, is a factor more or less in the pleasure derived during a hospital 
career, but sentiment is a personal affair. Desire for independence, 
distaste for idleness, and the high standard required in scholastic 
teachers, drive the upper classes into nursing. Qualifying examina- 
tions discourage hospital nurses of limited education. Nursing for 

' Murray'* s Magazine, August, 1890. 



THE MEDICAL CHARITIES OF THE ENGLISH METROPOLIS. 2$ 

livelihood and independence, coupled with a high motive and sym- 
pathy, forms a class from which comes the high estimation in which 
nursing is held, and supplies all the best matrons, sisters and nurses. 

Please understand that "sister" simply means the head nurse of a 
ward ; religious nursing sisterhoods have been tried in the London 
general hospitals and failed, chiefly, I think, owing to divided 
authority leading to want of subordination. At present there is but 
one survival, and that sisterhood finds head nurses of wards only ; 
all the other nurses are purely secular and handicapped, perhaps 
unjustly, because they can never in that hospital rise to be head 
nurses or ward sisters, the legitimate object of a nurse's ambition. 

To continue, Miss Stewart goes on to say that nursing is a happy 
life where there is a medical school ; interests, variety, all the science 
of the day, together with a freedom not usually enjoyed by single 
women in home life. Hospital life for women is rarely demoraliz- 
ing ; views enlarge, natures expand, the details of sorrow and sin 
widen nature without leaving a stain. Take, for example, the case 
of a ward sister confided in by her patients, and the trusted colleague 
of her medical officer ; this is happiness indeed. 

The position of the hospital nurse has been touchingly summed 
by. another clever writer :* — "To avoid being mawkish and senti- 
mental, and in the swing of reaction, we nurses are apt to treat the 
, patients in hospitals as mere material ; but if one realizes that the 
occupant of each bed is a human soul with its own rights and its own 
reserves — if one takes the trouble to knock at the door, in fact, and 
ask admission instead of leaping over the wall — life becomes pretty 
intense, a good deal gets crowded into a very few hours." 

Poor- Law Infirmaries, 

according to the conclusions of the committee, are well-managed 
institutions that require extension, as there is still an objectionable 
necessity for treating the sick poor in the sick wards of workhouses. 
These infirmaries have been established since the year 1867. 

I find Dr. Bridges, the Government medical inspector of these 
poor-law institutions, well puts their conception thus : — Formerly 
there existed no separate provision for chronic diseases amongst the 
destitute. They were "warehoused" in workhouses. Then Miss 
Louisa Twining began her work, and was succeeded by the " Lancet " 
Commission and the Act of 1867. Gradually the infirmary system 

* Mona Maclean, Medical Studtnt. London : Blackwood, 1893. 



26 CATHCART. 

was built up, after a separate struggle with the Board of Guardians 
in each Union. The underlying principle was adequate indoor relief. 
So gradual had the growth been that the medical profession were 
only just beginning to realize what had been done. If it had been 
less gradual, the ratepayers would have rebelled. That was a lesson 
of caution and patience in making further improvements. My friend 
Mr. Albert Pell, a great authority on matters relating to the poor 
and poor laws, gives this definition :r-The qualification for admission 
to a hospital is disease; to a poor-law infirmary destitution — I 
should say destitution together with disease. The evidence of Miss 
Louisa Twining, given before the committee, is very interesting; 
this lady is vastly respected, having done for poor-law medical and 
other institutions, and following in her footsteps, very much that 
which Miss Nightingale has done for hospitals and nursing in 
general. Of the poor-law infirmaries, fourteen are on the pavilion 
system. Chronic cases are sent to the infirmaries from the general 
hospitals, and these institutions are full of chronic cases of great 
educational interest. Publicity and increased medical visitation 
would, in my opinion, be most desirable. The committee was told 
that the interests and reputations of eminent medical men will 
maintain the general hospitals with schools; otherwise — and it would 
be calamitous — there would be a danger of the poor-law infirmaries 
swallowing up the voluntary hospitals. The committee was plainly , 
told that " the feeling of degradation in regard to a taint of pauperism 
is dying out." One witness said further that he was told by a poor- 
law medical officer that he was in the habit of urging the poor to go 
into the infirmary, calling it the parish hospital ; another medical 
man said he did not care how much a poor man's sensibility was 
rubbed ofT— from a medical point of view the thing is to cure. The 
evidence shows that the tendency within the infirmaries is to keep 
as much as possible out of sight and out*of mind the ugly and repel- 
lent words *' poor law " and ** pauper." 

The fever hospitals of the Metropolitan Asylums Board differ 
from the poor-law infirmaries, inasmuch as they take infectious dis- 
eases without regard to pauperism; these fever hospitals are working 
at high pressure, as will be seen by the following account, the last 
issued by the board. 

The chairman presented his annual report, which stated that 
during last year 13,093 scarlet-fever patients were received in the 
hospitals, an increase of 6556 over any previous year. During the 
year 46,074 cases of infectious disease were notified to the board, as 



THE MEDICAL CHARITIES OF THE ENGLISH METROPOLIS. 27 

against 26,522 in the previous year. The expenditure during the 
past year exceeded that of 1891 by 177,964/., which is attributed to 
the fact that 96,000/. was expended on the provision of temporary 
accommodation for the large number of patients by the erection of 
wooden buildings and furnishing them, and also on the erection and 
fitting up of the new hospital at Tottenham. 

It is most satisfactory to find that quite recently cHnical instruction 
in the fever asylums has been provided for under rules laid down by 
the Royal College of Physicians. 

The Hospital Saturday and Sunday Funds 

are mentioned in the conclusions of the committee, and the objects 
of these funds, and their methods of administration, are fully 
explained in the reports. 

The Sunday fund, now known throughout the world, is no doubt 
a valuable distributor for the busy and modest donor ; and consider- 
ing the turn-over in London is nearly 42,000/., the costs of collection 
and administration are on a scale of exemplary moderation. The 
Sunday-fund administration has promoted and prepared the way for 
desirable uniformity in hospital accounts, it has established to som^ 
extent a standard of efficiency, and hence it has appreciably invited 
and assisted wholesome comparison and criticism. And last, but not 
least, the Sunday fund limits on one Sunday at least the unholy war 
and strife of otherwise irreconcilable religious creeds and sects. 

The Saturday fund, which is of a self-helpful nature, a penny-a- 
week working man's fund, does not appear to gain much ground in 
London; the workshops in competition with the churches are 
nowhere. Let us hope this unfortunate state of affairs arises chiefly 
from want of knowledge and management. I am sure the working 
man is not lacking in appreciation and good will, and where, in com- 
bination, he does subscribe liberally, as in the case of a sick club, 
there is a very natural desire for a quid pro quo in the shape of 
so-called letters of admission. I would like to point out that one 
great underlying principle seems invariably to affect these funds in 
question, and all others of a like nature ; it is this : Experience tends 
to show that the amount of money available for religious and phil- 
anthropic purposes bears a fixed and definite proportion to the 

national income. 

Co-operation, 

The committee observes with regret the absence of any cordial and 
actuating desire for co-operation as between the various medical 



28 CATHCART. 

charities. On this point the valuable evidence, in the second volume 
of the Report, of Mr. Charles Stewart Loch, the Secretary of the 
Charity Organization Society, will well repay careful study. 

A Proposed Central Board, 

The committee in the last paragraph of the various conclusions 
contemplates and propounds a scheme for a central board, the essen- 
tial principle of which should be free co-operation. There is a table 
of suggested grouping of hospitals for purposes of representation on 
the central board. One great object of such board should be to 
secure the inter-co-operation of medical charity, and the co-operation 
of medical with general charity. 

It is satisfactory to observe that Mr. Burdett, in his comprehensive 
hospital annual for this year, tells us that a committee has been 
formed to consider the desirability or otherwise of creating a central 
board as suggested by the Lords' committee, and there is good 
reason to hope that a working and popular scheme may be arrived 
at. Another and very important work by the same author, " The 
Hospitals and Asylums of the World," is in many respects compli- 
mentary to the reports of the Lords* committee. Mr. Burdett gave 
valuable evidence before the committee, which evidence, in its 
entirety, I commend to those interested in hospital management. 

The general hospitals in London, the three endowed hospitals 
excepted, subsist mainly on legacies and windfall donations ; annual 
subscriptions usually do not suffice to pay wages, leaving nothing 
from this source for maintenance and administration. 

Lastly, we are brought to^his conclusion of the committee — in my 
opinion the most important outcome of the whole inquiry. It should 
always be borne in mind that the establishment of poor-law infirm- 
aries and rate-supported fever asylums under the Metropolitan Poor 
Law Act of 1867 has, in great measure, altered the relations between 
the poor and the hospitals, and everything associated with medical 
charity ; and the committee cannot shut its eyes to the possibility 
that, if some organization — a central board — such as that recom- 
mended is not adopted, a time may come when it will be necessary 
for voluntary hospitals to have recourse either to government aid or 
municipal subvention. 

Let me say, in conclusion, I am not, as regards my paper, in any 
sense a volunteer. I prepared this unworthy introduction to the 
Reports of the Lords' Committee on Hospitals at the desire of Dr. 
Billings, the distinguished chairman of your Chicago section on 



THE MEDICAL CHARITIES OF THE ENGLISH METROPOLIS. 29 

hospitals. I am far from wishing, even in the most remote degree, 
to appear didactic — I have a list of your own grand medical institu- 
tions before me ; if in America you excel in many things, or indeed 
in all things, I should from a feeling of common humanity, not to 
speak of our kinship, heartily rejoice. I would, however, remind 
you at least of one common interest, of one bond of union — the ever- 
illustrious surgeon of St. George's Hospital; his memory commands 
our keenest interests, our warmest sympathies. This is the centenary 
of John Hunter, the greatest name inscribed in those noble annals 
which together form the fame-breeding history of scientific medicine. 

Hunter died on October i6, 1793, in Leicester Square, having been 
taken suddenly ill on the morning of that day at St. George's Hos- 
pital. It was said of him at the time of his death, and the saying is 
true to our day :* 

'* The profession has lost in him one of its principal pillars and 
ornaments, and mankind may lament in him one of their best bene- 
factors. The ardor and success with which he cultivated natural 
knowledge and philosophy, and rendered them subservient to his 
profession, had deservedly raised him to the first name. The mon- 
ument of industry and genius which he has left behind will best speak 
his praise and call for the gratitude of this and future ages." 

John Hunter became one of the most brilliant of the fixed stars of 
our national genius, ** not so much by his contributions to the stock 
of human knowledge, which in themselves were colossal, as by his 
opening up a line of investigation which was entirely original, and by 
his marking out in the clearest way the paths which all future inves- 
tigators must tread who desire to decipher the problems of life, 
disease and death." 

It was well said the other day at Oxford' that medicine is one of 
the noblest of sciences ; that sober, absolute and positive science of 
medicine is but another name for works of mercy — the relief of 
human suffering in its most overwhelming form. The idea was 
further suggested — but the phraseology is my own — that the next 
generation of medical men will be fully occupied in considering how 
doth the little busy bacillus improve each dark and shining hour. 

Vast problems rapidly expand with a dense population such as 
that of Greater London ; certain I am "we must make a stand on the 
ancient way," relying as heretofore on the truly Anglo-Saxon combi- 
nation of private and public means. Reform, let us hope, will be on 

» The Oracle of October 18, 1793. * Lord Salisbury. 



30 



CATHCART. 



many lines, blending and harmonizing in the grand result. I have 
sometimes thought that I may personally have pushed inquiry to the 
extreme verge of conventionality ; if I have erred, I humbly make 
amends when I say that I have no prejudices. I have been trained 
from boyhood to evidence ; and as the result of this widely extended 
inquiry now in question, allowing for the imperfections which so clog 
all human affairs, knowing well that all things of earth are of the 
earth earthy, I have yet notwithstanding everything that is good 
and appreciatory to testify as regards the great voluntary medical 
charities of the English Metropolis. 

APPENDIX. 

The following summary was laid before the Committee at its first meeting : 

Hospital and Dispensary Accommodation op all kinds in the 

Metropolis, with totals of In- and Out-Patiknts : 

Income and Expenditure. 



4,525' 3,398 

I 
I 

74?! 420 
3.6i6i 2,553 



General Hospitals 
with Schools 

(■■) 

General Hospitals 
without Schools 

(8) 

Special Hospitals 

(67) 

Free Dispensaries 
(26) 

Part-pay Dispen- 
saries (13) 

Provident Dispen- 
saries (35) 

Poor-law Infirma- 
ries and Sick 
Asylums (27) ..111,9051 9,639 

Poor-law Dispen- 
saries (44) 

Surgical Appa- 
ratus Societies . 

Hospitals for In- 
fectious Dis- 
eases (8) 



j No. of 
No. of occu 



beds. 



pied 
beds. 



2,766 



Totals 123,550117.830 



1,820 



3 


4 


In. 


Out- 


patients 


patients 


in one 


in one 


year. 


year. 


44,364 


551,663 


5,684 


107,151 


26,850 


398,038 


• • 


162,219 


• • 


102,302 


• • 

18.5^6 


125,674 

1 
.. 1 



114,983 
23.351 



5 


6 


Total ex- 


Total 


penditure. 


income. 


£ 


£ 


389,499 


356,894 


41.577 


40,147 


244.691 


254,669 



21,257 

9,710 

16,287 



19,984 



6.593 J 29.31 3 
1 22,047 ! 1 ,58 5,38 1 1 1 ,208,523 



Diflerence 
between 
total ex- 
penditure 
and total 
income. 



19,254 
8,996 

16,298 



— 32,605 

— 1,430 
■f 9,978 

— 2,003 

— 714 
+ II 



336,205 336,205, 



19,984 
15,717 

I 29,313 
1,197,477 



EDUCATIONAL STANDARDS FOR NURSES. 3 1 



EDUCATIONAL STANDARDS FOR NURSES. 

Isabel A. Hampton, 

Superintendent of Nurses and Principal of the Training School^ The Johns 

Hopkins Hospital, 

While fully appreciating the honor done me by our Chairman, it 
has not been without much hesitancy that I have undertaken to 
express my views upon so important and complex a subject as 
** The standards of education for nurses." The subject is important 
because it deals with the problems of health and disease, of life 
and death. It is complex because so many diverse factors and 
interests must be taken into consideration. The social problems of 
human misery and suffering and how best to alleviate them have 
been wonderfully worked out since the days when Charles Dickens 
first began to exert the power of his genius upon the mind of the 
public in order to bring it to an active sense of its responsibility in 
such matters, and perhaps in no branch of philanthropy has the 
change been so marked as in the care of the sick of all classes in all 
countries. And when we consider the few years which have elapsed 
since the modern system of nursing has been introduced, and contrast 
the present conditions with those which formerly prevailed, we might 
at first sight perhaps be excused if we regarded our present methods 
with some complacency instead of all the time struggling to find 
room or ground for improvement. But with progress going on in 
every branch around us, are we alone to stand still ? 

The present history of hospitals in America shows that the 
hospital nursing is with few exceptions already being done by the 
members of regularly organized schools for nurses, and that where 
such schools do not exist steps are being taken for establishing them. 
Next, we find that the demand for trained nurses is steadily on the 
increase for cases of sickness in private families, and what is still 
more important, that district nursing is being introduced into almost 
every large city in the country. Then, too, missionary boards are 
requiring that their women for foreign work shall prepare themselves 
by receiving a course of training in nursing. Lastly, when we see 
that women are beginning to look upon a thorough knowledge of 
nursing as an essential groundwork for their medical education, we 
cannot but be convinced that training schools for nurses and trained 



32 HAMPTON. 

nurses are established facts — important factors in hospitals, in houses, 
and for the community at large. 

In considering the standard of education requisite for such workers 
we have to consider (i) the kind and quality of the work required, 
and (2) the order of woman necessary to meet such requirements. 

In the daily routine of a hospital, with its variety of patients, the 
work of a nurse, even while herself receiving instruction, is not without 
its immediate results. The hospital is her workshop in which she 
must serve an apprenticeship, and from the day she enters it the 
preservation of human life and the alleviation of human suffering are 
to some extent delivered into her hands. Can a woman, in any other 
kind of work which she may choose for herself, find a higher ideal or 
a graver responsibility ? Where human life and health are concerned, 
what shall we term " the little things " ? . 

Again, in the progress that medical science is making she has her 
allotted part to perform. To be sure she is only the handmaid of 
that great and beautiful science in whose temple she may only serve 
in minor parts, but none the less is it her duty to endeavor to grasp 
the import of its teachings, that she may fulfil wisely her share. It 
requires, for instance, more than mechanical skill on the part of a nurse 
to follow the preparations for an antiseptic operation, full of signifi- 
cance as it is in every detail, and the saying that *'dust is danger" 
must have a bacteriologically practical application in her mind. Nor 
can just any one appreciate the full meaning of the physician when 
he says ** the nursing will be half the battle in this case." For the 
simple performance of nursing work such knowledge is requisite, but 
when the wider duties of either head-nurse in a hospital or principal 
of a school for nurses are assumed, where one must not only know, 
but be capable of imparting that knowledge to others, then the 
responsibilities become proportionately greater. 

Turning from hospitals to consider the requirements for this work 
elsewhere, we find that nursing in private families and district nursing 
among the poor in their homes are the two great fields in which 
the nurse will be principally occupied. Here she is frequently even 
more closely identified as the physician's lieutenant, for whereas in 
a hospital a doctor is usually within ready call to render either 
advice or assistance, on the other hand in private practice her knowl- 
edge and skill in the absence of the physician must be depended 
upon in critical illnesses or unlooked-for complications until his aid 
may be secured. To this part of the work in particular may be 



EDUCATIONAL STANDARDS FOR NURSES. 33 

applied the following words taken from a physician's address dealing 
with the relation of the nurse's work to that of the physician : " The 
hands of a nurse are the physician's hands lengthened out to minister 
to the sick. Her watchful presence at the bedside is a trained 
vigilance supplementing and perfecting his watchful care ; her knowl- 
edge of his patient's condition an essential element in the diagnosis 
of disease ; her management of the patient, the practical side of med- 
ical science. If she fails to appreciate her duties, the physician fails 
in the same degree to bring aid to his patient." 

In district nursing we are confronted with conditions which require 
the highest order of work, but the actual nursing of the patient is the 
least part of what her work and influence should be among the class 
which the nurse will meet with. To this branch of nursing no more 
appropriate name can be given than "instructive nursing," for 
educational in the best sense of the word it should be. 

Realizing, then, the kind and quality of the work to be done, we 
pass on to the consideration of the order of woman required to 
perform such duties, and those of us who have had much experience 
with nurses, and know all we would have them to be, and how much 
they really must be, as the various classes of women pass in review 
before our mental vision, will be inclined to agree with the writer of 
a letter which came to me a short time since. After asking me to 

recommend a head-nurse for a hospital, and enumerating at length 

* 

the qualities she must possess to be successful, he concluded with 
the words, " In short, we require an intelligent saint." The idea 
still prevails in many minds that almost any kind of a woman will 
do to nurse the sick, and that the woman who has made a failure 
of life in every other particular may as a last resource undertake 
this work. After many years of continuous work among patients 
and nurses, I am convinced that a woman, to become a trained 
nurse, should have exceptional qualifications. She must be strong 
mentally, morally, and physically, and to do thorough work she 
must have infinite tact, which is another name for common sense. 
She should be as one of the women of the Queen's Gardens in 
Ruskin's Sesame and Lilies^ or such an one as Olive Schriner 
describes when she says, " A woman who does woman's work needs 
a many-sided, multiform culture ; the heights and depths of human 
life must not be beyond her vision ; she must have knowledge of 
men and things in many states, a wide catholicity of sympathy, the 
strength that springs from knowledge and the magnanimity that 



34 HAMPTON. 

springs from strength." Only in so far as the women of our training 
schools attain to this standard will the institutions and communities in 
which they labor feel and show forth the influence of that " sweet 
ordering, arrangement and decision" that are woman's chief pre- 
rogatives. What class of women have the same practical privileges 
of learning the means to be used for the prevention of disease or 
of realizing their importance? Who then is so competent or who 
has greater opportunities for daily practising these than herself, and 
teaching them to others? And intelligent she ought and must be 
to do this wisely; otherwise she is a mefe machine, performing 
mechanically the task before her, not knowing why or caring for 
what it all means, and the public loses thereby the services of one 
who should be valuable in showing them something at least of the 
beauty of the laws of hygiene and their application, and who can 
fortify her teaching with scientific facts. 

Let us then consider (i) what is the present standard for the 
trained nurse, (2) what are her educational advantages, and (3) in 
what ways is she deficient ? 

The object of schools for nurses is primarily to secure to the hos- 
pital a fairly reliable corps of nurses ; and it is in order to insure a 
continuous source of supply that such schools are established and 
certain inducements are offered to women to become pupils in them. 
These inducements are set forth in the circulars of general informa- 
tion published by each school. But when one compares these circu- 
lars, the teaching methods of no two schools will be found to be alike, 
all varying according to the demands of the various institutions and 
their several authorities. Each school is a law unto itself. Nothing 
in the way of unity of ideas or of general principles to govern all exists, 
and no effort towards establishing and maintaining a general standard 
for all has ever been attempted. Some institutions consider that a two 
years course of instruction is essential ; others place it at a year and 
a half; and others again at a year. In England a few schools insist 
upon three years. The hours of daily work also differ widely, some 
requiring from their pupils nine hours a day of active service; others 
as high as twelve an|l thirteen hours. The theoretical instruction is 
usually not included in the nine hours work, and it is difficult to 
speak definitely upon this subject, as the length of such a course, 
the subjects and the extent to which they are taught are again 
dependent upon the opinion upon this matter of the governing body 
of each particular school. We also find no general rule governing 



EDUCATIONAL STANDARDS FOR NURSES. 35 

the Special attainments or degree of education required from the 
women who present themselves as candidates. On the contrary, a 
woman who has been refused by or dismissed from one school for 
lack of education, dishonorable conduct, ineflSciency, etc., frequently 
gains admittance into another, where the authorities have not so 
high, if any, standard required from those whom they accept.. But 
notwithstanding all these differences, each woman who graduates 
from any of these schools usually has a document with the high- 
sounding name of diploma presented to her, and henceforth she is 
known as a '* trained nurse," which in nowise indicates what amount 
of knowledge or fitness she really does bring to her work. In fact 
it is no unusual occurrence for schools to graduate nurses whom 
they at once, when relieved from their presence in the hospital, 
refuse to recommend or sustain in their work. 

A " trained nurse " may mean then anything, everything, or next 
to nothing, and with this state of affairs the results are far from what 
they should be, and public criticism is frequently justly severe upon 
our shortcomings, or else is content with superficiality where like 
meets like. This criticism falls both upon the woman herself and 
up9n the institution which she represents. Sometimes the one only, 
in others both deserve censure. Can a woman be expected to give 
properly a hypodermic injection to a patient if her school has never 
taught her how this is to be done ? The school and not the nurse 
is to be blamed for her ignorance in such a case. Or again, abscesses 
may follow such injections unless the nurse has been taught the 
practical significance of antisepsis. Or again, can she be expected 
to have at her fingers' ends the principles and practice of invalid 
dietary when she has never been practically taught such a thing ? And 
when a really capable woman realizes that she does not know enough 
to do her work sufficiently well to honorably receive the full com- 
pensation of a skilled nurse, and that she is not worthy of such res- 
ponsibility, and if she is willing to give up more time and labor to go 
once more into a hospital where she may be really taught what she 
wants to know, where shall we find one capable school willing to 
take her? For we wish to mould our own fresh material, not being 
Michael Angelos to make Davids out of others* failures. Sadly 
frequent, too, are these requests made to the authorities of our larger 
schools, and in most instances they are the fruits of the systems 
prevailing in our smaller hospitals and sanatoriums. Such places 
are legitimate enough in their way, and indeed many are very 



36 HAMPTON. 

necessary, still the mere fact that they are hospitals in nowise justifies 
them in establishing training schools for the sake of economy, and 
accepting as their pupils women who, perfectly ignorant of what they 
need, go to them and give up a year or two years of precious time, 
and then find that their education has been thoroughly inadequate 
to enable them to fulfil what is afterwards required of them. We 
cannot but feel that a real injustice is often done in such cases. If 
the nurse had gone into such a hospital as a philanthropist it 
would be different, but she went there for the purpose of acquiring 
a certain kind of education. Again, these small hospitals, not 
having the same number to select from as the larger schools, are 
apt, and in fact do take women who, not being intellectually capable 
of comprehending the high calling into which they have been 
admitted, tend to lower the standard to which we are striving to 
attain. As an instance of such small hospitals which have come to 
my notice while writing on this subject, I have in my mind one, the 
superintendent of which informed me that their hospital contained 
30 beds and that they had a training school of 11 nurses. But 
the most pernicious of small hospitals is the specialty hospital or 
private sanatorium, which owes its existence solely to the desire of 
the owner to make money for himself, and in which a training school 
is organized for the sake of securing cheap nursing, with an utter 
disregard for the interests of the women employed. One doctor 
who owns such a hospital with 25 beds has 16 nurses, who are given 
a two years' course in this particular specialty, but four of these 
nurses are actually sent to his private patients at $25 per week, this 
money going to the hospital, while the nurse receives $16 per month. 
This brings us to the question of the advisability of sending nurses 
out of the hospital into families during the second year of their train- 
ing. It is true that such a procedure materially assists in the main- 
tenance of the hospital, and to some institutions it is very necessary, 
but is it exactly what should be done in the best interests of the 
education of the nurse ? The majority of schools make the statement 
in their general circular that they reserve the right to send their 
pupils out to private duty during their second year, in order to help 
to meet the expense of their maintenance and education. This may 
have been all well and good in the earlier schools when hospitals 
were not so numerous in the land and when the question of sup- 
porting them was a more serious difficulty than now. The addi- 
tional expense of maintaining a school was not to be thought of, 



EDUCATIONAL STANDARDS FOR NURSES. 37 

and it was thus necessary to appropriate some of the pupils* time 
towards providing an income. But now that wealthy philanthropists 
and societies are erecting hospitals of all kinds, they should see to 
it that the question of maintaining a nursing corps is provided for, 
instead of expecting the nurses to do philanthropic work by earning 
money to support the hospital at the sacrifice of their own education. 
As a matter of fact the services rendered by a good training school 
to a hospital are sufficient to warrant the expenses incurred by the 
school, for in any case a certain amount of work has to be performed, 
and for those who do it the hospital would be obliged to provide 
board and lodging or the equivalent in money besides the regular 
wages. Under what other system then could an equally efficient 
class of workers be secured in the same systematic way, giving a full 
nine hours service daily and receiving financially less than the ward 
maids ? It is understood that the equivalent is to be made up by 
the education given. Is it not then a most serious responsibility on 
the part of such hospitals or training schools to see that the educa- 
tion is made as complete as possible ? 

After much practical experience, I maintain that no such course 
of education can be thoroughly given in one year, but yet I find 
that very many schools limit their didactic teaching to the first year 
and make the second year's work of a purely practical nature and 
divide it between hospital work and private duty. It is absolutely 
necessary that class work and lectures should be carried on through 
the second year as well, and if this is done, then private nursing 
outside of the hospital is out of the question, as such interruptions 
would seriously interfere with any systematic teaching. I also hold 
that it is necessary to have the pupil under the daily observation 
and criticism of her teachers. This is impossible if she leaves the 
hospital for private duty, and one of two things must be true, viz: 
either she is as yet unfit to be entrusted to do her work without 
some supervision, or else, if she is really capable of doing this 
work in the second year she should not be held by the school at 
all. In the latter case, why not make the term of pupilage only 
one year and graduate her ? There is another side to this question, 
that of justice to the patient, but as this does not really come 
under the head of the standards we are just now discussing we will 
pass it by. 

It may seem that I find little that is good in the system at present 
followed in our training schools. I am far from wishing to disparage 



38 HAMPTON. 

pioneer efforts, but I would maintain that now that our oldest school 
in America has attained to its majority, we can no longer fall back 
upon the plea that our art is still in its infancy. Our founders 
achieved well and nobly, but it surely was not intended that we should 
work on forever on the old lines. There are plenty of problems to 
work out, and schools for nurses are capable of much finer work 
than has yet been done, if we to whose hands the work is now 
entrusted are willing to take a broad and comprehensive view of the 
subject. The principal of a school for nurses performs the least part 
of her duty, and throws away many of her privileges, if she is con- 
tent to confine herself to the limitations of her own particular school. 
She must look into and go abroad among other schools, and teach 
her nurses to do the same, recognizing what is good in others and 
being ever ready to adopt any improvement. There is so much 
that we can learn from each other, and sooner or later we must 
also recognize the fact that we are all trained nurses, and that until 
something of a common standard is reached the imperfections of the 
few must be borne by all. Briefly, then, some of our chief aims 
should be to bring about a spirit of unity among the various schools, 
and to establish a standard of education upon which we may all be 
judged. This of necessity must be based upon the opinions of no 
individual mind or committee, but upon the consensus of the impar- 
tial judgments of many really experienced in the requirements for 
such work; for in this way alone can we command a thoroughness 
of work and a selection of women that we cannot now boast of. In 
doing this, the first step should be to bring about in all our schools, 
as far as possible, a uniform system of instruction, so that the 
requirements for .graduation should be about the same in each. 
We might well lengthen the course of instruction in training schools 
to three years, with eight hours a day of practical work. This 
would relieve the hospital and school of having to deal with so 
much new material at so frequent intervals. It would then be pos- 
sible to select our nurses much more carefully than can sometimes 
be done, for it happens at times that vacancies occur which must be 
filled without waiting for the right candidates to present themselves, 
and it would insure far better results by securing to the hospital 
nurses with more practical experience. 

A school naturally divides itself into two classes, the quite com- 
petent and those who are fairly competent. The first division is apt, 
bright, intelligent, and readily taught, and at the end of the second 



EDUCATIONAL STANDARDS FOR NURSES. 3/ 

and it was thus necessary to appropriate some of the pupils* time 
towards providing an income. But now that wealthy philanthropists 
and societies are erecting hospitals of all kinds, they should see to 
it that the question of maintaining a nursing corps is provided for, 
instead of expecting the nurses to do philanthropic work by earning 
money to support the hospital at the sacrifice of their own education. 
As a matter of fact the services rendered by a good training school 
to a hospital are sufficient to warrant the expenses incurred by the 
school, for in any case a certain amount of work has to be performed, 
and for those who do it the hospital would be obliged to provide 
board and lodging or the equivalent in money besides the regular 
wages. Under what other system then could an equally efficient 
class of workers be secured in the same systematic way, giving a full 
nine hours service daily and receiving financially less than the ward 
maids ? It is understood that the equivalent is to be made up by 
the education given. Is it not then a most serious responsibility on 
the part of such hospitals or training schools to see that the educa- 
tion is made as complete as possible ? 

After much practical experience, I maintain that no such course 
of education can be thoroughly given in one year, but yet I find 
that very many schools limit their didactic teaching to the first year 
and make the second yearns work of a purely practical nature and 
divide it between hospital work and private duty. It is absolutely 
necessary that class work and lectures should be carried on through 
the second year as well, and if this is done, then private nursing 
outside of the hospital is out of the question, as such interruptions 
would seriously interfere with any systematic teaching. I also hold 
that it is necessary to have the pupil under the daily observation 
and criticism of her teachers. This is impossible if she leaves the 
hospital for private duty, and one of two things must be true, viz : 
either she is as yet unfit to be entrusted to do her work without 
some supervision, or else, if she is really capable of doing this 
work in the second year she should not be held by the school at 
all. In the latter case, why not make the term of pupilage only 
one year and graduate her? There is another side to this question, 
that of justice to the patient, but as this does not really come 
under the head of the standards we are just now discussing we will 
pass it by. 

It may seem that I find little that is good in the system at present 
followed in our training schools. I am far from wishing to disparage 



40 HAMPTON. 

school, and often the new superintendent herself suffer accordingly 
while she is gaining the necessary experience. In fact a Normal 
School for preparing women for such posts is quite as necessary as 
those established for other kinds of teachers. 

The eight-hour system will also be advisable, for the reasons that 
the health of the nurses will not bear the strain of a three years' 
course with longer hours ; besides, is it not poor economy and mis- 
taken judgment for a country to sacrifice the health of one class of 
people in trying to restore that of others ? 

Then it would do away with the continual breaks in the day's 
work caused by the half-day and two hours recreation system, and 
if a systematical course of theoretical teaching is entered upon, 
shorter hours of practical work are absolutely necessary, as the over- 
powering physical weariness following a long day's work makes 
mental effort out of the question, and to require tired-out women to 
attend evening lectures after nine hours of physical exertion, and 
the mental excitement attendant upon hospital work, is little short of 
tyranny. And this mental development is necessary for the best 
results in the work if we would command the services of an intelli- 
gent class of women. 

In considering standards of education for nurses we must not 
overlook the smaller hospitals, cottage hospitals, etc., for they have 
their work to do as well as the large institutions, but that they are 
in no position to offer adequate teaching or experience to a woman 
who would become a thorough nurse is very evident. 

How then can we meet the problem of supplying good nursing, and 
at the same time making good nurses ? It can only be met by 
the larger schools entering into arrangements with the smaller schools 
to supplement their teaching. This plan, of course, would require 
that the standard of women and of education should be the same, and 
the teaching on practically the same basis, while the head-nurses of 
the smaller schools must be thoroughly competent women. In a 
city where distances are not too great, one school may successfully 
undertake the care of two or three hospitals. For instance, a 
children's hospital may better be associated with a general training 
school, and the same holds good with a hospital dealing with obstet- 
rics, or with any other special branch. As for private sanatoriums 
owned by private individuals, the nursing should unquestionably be 
done by salaried nurses who have graduated from some reputable 
school. . 



EDUCATIONAL STANDARDS FOR NURSES. 4I 

A final word as to the practical qualifications which should be 
required of women who present themselves as candidates to be 
taught nursing. A good practical English education should be 
insisted upon. By this is meant that the candidate should come up to 
the standard required to pass the final examinations in the best high 
schools in the country, special stress being laid upon her ability to 
express herself either in writing or orally with quickness and 
accuracy. Her knowledge of arithmetic should be of an eminently 
practical nature and so that she can readily deal with problems 
involving fractions, percentage, bookkeeping, etc. This much is 
absolutely necessary. Of course more than this is desirable, as no 
other study develops the reasoning powers in the same practical way, 
and women who do not possess any education in arithmetic beyond 
the few simple rules, simply applied, are at once placed in a disad- 
vantageous position upon entering upon their work in a modern hos- 
pital. Of course, if she has in addition a knowledge of languages 
and a broad general reading, the candidate is all the better prepared 
for undertaking and obtaining success in her career as a nurse. 

Aside from this mental equipment there are other qualifications of 
a practical nature that should be insisted upon. Every woman before 
entering upon hospital work should be a thoroughly trained house- 
keeper. Practical household economy should be a part of her home 
education^ for in hospital wards the nurses are the stewards, the care- 
takers of the hospital property, and upon their thrift and careful 
ordering must depend the economical outlay of the hospital funds. 
I cannot dwell upon this practical household economy with too great 
emphasis, for experience has shown me to a painful extent how this 
branch of woman's work is neglected or superficially understood by 
so many women in all ranks of life. A total lack of or appreciation 
for the principles that govern such work will inevitably be followed 
by a deficiency in thoroughness and system. In the nurse should be 
found evidences of this practical knowledge; it should be seen in the 
way she cares for her own room, her personal appearance, and in the 
order and system which attends any work to which she puts her hand, 
and her knowledge of the value of the articles she has to work with 
should be shown by the way she cares for them. But too often, 
alas ! training schools are obliged to not only teach in two short years 
all that pertains to nursing, but try as well to teach the first princi- 
ples, at least, of domestic science, and much valuable time is spent in 
doing this that should really be given to nursing. When a graduate 



42 BURDETT. 

nurse gfoes into a private family and earns the just reproach of being" 
extravagant and careless in the care of property, and when the 
details of her work are without finish, the blame should be put down 
to her early home training and not to her training as a nurse. 

Time does not permit me to more than touch upon some of the 
most glaring defects in our system of nursing and to outline very 
briefly some changes that might be of general advantage, but I trust 
that sufficient has been said to arouse interest enough among hos- 
pital and training school workers to induce them to persevere in 
working out the problems, the solution of which will give us more 
united work and a more uniform standard of education for all who 
are to go out into the world as trained nurses ; for only from institu- 
tions in which the head, the heart and the hand are trained to work 
together in harmony can come forth the true nurse. 



HOSPITAL FINANCE AND METHOD OF KEEPING 

ACCOUNTS. 

Mr, Henry C. Burdett, of London, England, then made the fol- 
lowing remarks upon Hospital Finances and the Methods of Keeping 
Accounts : 

** Finance is the keystone of the arch upon which all institutions 
stand. Its condition is the test of sound management, without which 
it is certain that we should be much better off without than with our 
institutions. The subject of finance may be treated from the income 
side, bringing out very forcibly the differences and the advantages 
and disadvantages of the various systems prevailing in different 
countries. But I must leave this side of the question untouched, 
and, in these remarks, will deal only with expenditure. 

It has been stated as an axiom that the best hospital administration 
aims "to cure the greatest number of patients with the smallest 
number of beds, in the shortest time, at the least expense." This 
may be good economy, but in hospitals the principle may be carried 
too far. At my first visit to Chicago, in 1882, I found its largest 
hospital in such a condition that I felt I must do as I did on a similar 
occasion in Dublin, — return to my country with sealed lips ; because 
I believe that if a correct and literal account had been given of the 
condition of affairs which I found in it, it would have staggered this 
city, and it certainly would have astonished others. 



HOSPITAL FINANCE AND METHOD OF KEEPING ACCOUNTS. 43 

It is quite wrong for any institution to endeavor to treat at any 
time more patients than it has adequate provision for. I have seen 
in one of our largest hospitals in England two wards, managed by 
different physicians — one admirably administered, and the other 
overcrowded, with a bad atmosphere and suffering patients. The 
physician who controlled the crowded ward had a kind heart, as it 
was said, while the other physician was more strict in his manage- 
ment, and would accept no more patients than could be properly 
cared for. It appears to me that kind-heartedness which introduced 
extra beds into wards intended to contain a certain number calculated 
for the best interests of the patients, is a form of kindness from which 
the world has suffered too much. 

It has been stated that it is impossible that different hospitals shall 
prepare and publish accounts upon a uniform basis. All I can say 
to this is that if, after eighteen hundred years of Christianity, we 
have not yet become able to devise a fairly uniform system which 
will be accepted by intelligent men and women as a reasonable 
method of statement of accounts, the experience of these eighteen 
centuries has been to very little purpose. I have found, in discussing 
this question for individual institutions, that the administrators did 
not find it very difficult to accept a system which would give 
uniformity and require very little change in their present methods of 
accounts. The following appears to me to be the best system for 
hospital accounts. Every report should contain : 

(i). An Income and Expenditure Account, containing a detailed 
statement of the receipts and expenditures under classified heads. 

(2). An Invested Property Account, showing all the property of 
the institution, the various securities held, and the income derived 
therefrom. 

(3). A Balance Sheet. 

(4). A Special Appeal Account. This should show all the money 
received as the result of appeals or personal canvassing, apart from 
old subscriptions, the Hospital Sunday and Saturday Funds, and 
other regular and assured sources of income. It should also show 
every item of expenditure connected with the issue of these appeals, 
including advertisements, salaries, commissions, printing, stationery, 
postage, and every other item of the kind. Such an account enables 
any governor to keep an eye upon the management, and to ascertain 
if the efforts put forth are adequate to the purpose, and if they 
combine the minimum of expenditure with the maximum of results. 



44 BURDETT. 

If there are any special funds, such as a Samaritan Fund, a Con- 
valescent Fund, a Chaplain's Fund and so forth, a separate statement 
should appear in the report in each case. 

Turning now to the books which it is desirable to keep, I may 
deal with them under two heads. 

I. Receipts, — These should include: i. a Cash Book; 2. a Cash 
Analysis Book; 3. a Subscriber's Register; 4. a Legacy Book; and 
5. an Invested Property and Rent Book. 

The Cash Analysis Book will contain, under their proper heads, 
every item of receipt throughout the year, and the total of each 
column, i, e. donations, subscriptions, investments, and so forth, 
should agree with the total given in the published accounts, as well as 
with totals given at the end of the lists of subscriptions, donations, 
legacies, and invested property, published in the report This is 
easily arranged by having two columns in the report, one showing 
the amount of former subscriptions and donations received from 
individuals, and the other, amounts received from each during the 
past twelve months. 

II. Expenditure, — The books required to keep a correct account 
of the expenditure of public institutions are : i. The Analysis Jour- 
nals ; 2. a Journal; 3. a Ledger; 4. a Wages Book; and 5. Petty 
Cash Hooks, — one, at least, for the secretary, and one for the matron 
or lady superintendent. 

I must confess that during the last twenty years I have at times 
madtr large demands upon the patience, kindness and good will of 
the officers of various hospitals throughout the country. I have often 
troubled them with inquiries and requests for the filling up of various 
forms, involving the expenditure of a considerable amount^of time and 
labor and the exercise of no little patience and care. I am happy to 
take this opportunity to publicly thank the whole body of hospital 
officials lor their generous co-operation and courtesy. I have, of 
course, always been ready to assist anybody with information of facts 
when application has been made to me, and so I am proud to think 
a feoling of confidence has grown up between myself and the officials 
which enables us to trust and help each other to an extent which I 
believe has been fruitful in results to the benefit of the charities in 
which we are so greatly interested. I should like to make some 
definite return for all the kindness I have received. Many of the 
inquiries and most of the returns would have been unnecessary had 
the accounts, of the larger institutions at any rate, been kept upon 



I 
\ 



HOSPITAL FINANCE AND METHOD OF KEEPING ACCOUNTS. 45 

something like an identical plan. Unfortunately, where the man- 
agers have endeavored to follow a particular form of accounts they 
have naturally adopted their owi) method of classification, and so the 
attempt has largely failed to accomplish what is desired. For 
iostance, it is a common thing to find alcohol, i, e,, wine and malt 
liquors, placed in one report under " Provisions " ; in another, under 
"Surgery and Dispensary"; and, in a third, under a separate head- 
ing of its own. Very many other items are treated in an equal variety 
of ways, and so the reports are most difficult to analyze, and it is 
almost impossible for any one, even with the largest experience and 
knowledge, to compare the expenditure of one institution with that 
of another upon an identical basis. 1 have, therefore, thought that I 
might make some little return for the kindness I have received if I 
published a glossary as an appendix to the system of accounts 
which I am about to explain to you, and the heads of which I have 
already given. I have this glossary here on the table before me. 
It has been compiled with commendable diligence by Mr. Michelli, 
the secretary of the Seaman's Hospital of Greenwich, and I hope 
that in the course of the evening some of you will put it to the test, 
by asking through the Chairman under what head particular items 
are to be classified. I have also arranged that leaves from the vari- 
ous b6oks, together with this glossary, and a brief explanation of the 
system, shall be given in the forthcoming edition of the Hospital 
Annual, so that persons who are interested in the matter may be 
able to study them at leisure, and, if they please, to alter their system 
of accounts, and so obviate the necessity for many, if not for all, 
the inquiries so frequently addressed to them under existing circum- 
stances. Such a general system of accounts, if generally adopted, 
must tend to secure to the officials no small amount of comfort and 
advantage. 

Finally, I may say that I have prepared an analysis of the accou%ts 
of all the chfef hospitals throughout the country upon an identical 
basis, the whole of which will appear in the Annual.*' 

Mr. Burdett explained his system of accounts, illustrating his 
remarks by reference to large diagrams of the various books. 



THE APPLICABILITY OF HYGIENE TO THE 
CONDITIONS OF MODERN WARFARE. 

By Lieut.-Colonel J. Lane Notter, M. A„ M.D., 

Army McdUal Staff ; Professor of Military Hygiene, at (hi Army 
Mtdictil School. NetUy. 

I offer no apology for bringing forward this subject, for since iS6o 
England has practically been annually engaged in some form of 
military expedition or other in various parts of the globe, and has in 
consequence gained an experience in practical sanitation in war 
unequaled by any other country. I venture, as the representative of 
that army, to bring forward some considerations as to how far, con- 
sistent with the exigencies of modern methods and conditions of 
warfare, the general principles of hygiene can be applied with a view 
to mitigating, if not obviating, much of the disease and suffering inci- 
dental to military operations ; at the same time not losing sight of 
the fact, that notwithstanding the greatest efforts [he hygienic ideals 
of peace-time are impossible of attainment during a period of war. 

Inasmuch as the raison d'^lre of the existence of a standing army 
at all is essentially the drilling, training and preparation of the indi- 
vidual soldier for purposes of war, we find that the very first care is 
the proper selection of troops, and in making this selection we find 
these factors prominently asserting themselves ; they are size, weight 
and age of the men. 

The consideration of these factors is essentially one for peace-time, 
and a nation having once committed herself to war has no choice 
left in dealing with these matters, but every available man must be 
utilized for military service, regardless of temperament, age or any 
qjher consideration, 

While the hygienic bearings of military life are fairly simple in 
peace-lime, the moment war breaks out we find the condidons alter 
materially, in fact so much so that all hard-and-fast rules or precon- 
ceived ideas as to the attainment of a perfectly hygienic mode of hfe 
by an army in the field are practically impossible. To state this 
briefly, the only hygienic methods possible are those which the 
circumstances of time and place admit of. We must use whatwe can 
get, taking care, however, to arrange the work and condition of 
labor which the individual has to perform as much as possible in 




APPLICABILITY OF HYGIENE TO MODERN WARFARE. 47 

accordance with our hygienic ideal. Being in a state of war, this will 
naturally be difficult to state in its entirety. 

Food and Drink, — The feeding of large masses of men in the field 
will need to be conducted on the same dietetic principles as the feeding 
of similar multitudes in peace-time. The main points on which this 
will differ will be absence of regularity and difficulty of supply ; the 
former must necessarily be subordinate to military exigencies, but 
the importance of regularity in feeding should never be lost sight of. 

As to the nature of the supply, in the present day of excellent 
methods of preservation of food-stuffs, little difficulty is likely to arise, 
provided the transport arrangements are adequate. The mainte- 
nance of a regimental supply-unit would seem to be preferable to the 
larger one by brigades. In fact, to adequately carry out a proper 
supply the regimental unit should be rigidly adhered to. It should 
also be clearly understood that the emergency ration is purely a 
supplementary one, and in no case ought to be reckoned as a part of 
the ordinary field ration. 

As concerns the supply of drink to an army in the field, water 
must necessarily form the staple element. With an advancing column 
systematic filtration is impossible. Reliance will have to be placed on 
simply boiling the water before filling the water-bottles. When this 
cannot be done, the only safeguard will be that of selecting the purest 
supply possible. Men should be taught the danger likely to follow 
on drinking water the source of which is unknown, unless this has 
been previously boiled. If a filter is to be employed at all, some 
form of the Chamberland-Pasteur seems to be the best ; but as vet 
no form at once portable and easily used has come under my notice. 
All medical officers are unanimous in condemning the issue of alcohol 
as a ration in the field. The only form in which it is admissible is in 
the form of light red wines, which are best taken when freely diluted 
with water. The consensus of opinion on this point is so unanimous 
that further reference need not be made here. 

Preventable Diseases, 

Within the scope of this paper it is impossible to deal with the 
many diseases incidental to warfare. Briefly stated, those which most 
frequently render men non-effective are diarrhoea, malaria, heat- 
stroke, and footsoreness. These are all more or less preventable. 

Diarrhoea. — In the field, diarrhoea is a disease which is early met 
with, consequent on a change of food and chill. It has occurred in 



48 NOTTER. 

every expedition, and is frequently followed by enteric fever ; the 
passage of the one disease into the more severe being rapid, and 
increasing as the age of the men composing the force diminishes, the 
younger men suffering the most. In camps and on the march the 
latrines should be kept in a perfectly sanitary state, and as disin- 
fectants are not always available, they should be dug deep and 
narrow, and covered in with six inches clean earth daily, the same 
trench not being used for many days in succession. Men suffering 
from diarrhoea which does not yield in a day or two to simple reme- 
dies should be passed on to the field hospitals for further treatment. 

Malaria. — As regards malaria, little can be done on service to 
make a temporary site in a malarious country healthy. Any form 
of subsoil drainage is impossible, and the rule should be not to occupy 
such positions longer than actual necessity obliges. With the 
rapidity of movement incidental to modern methods of warfare, men 
will seldom remain sufficiently long in one place to undertake work 
of any permanent character. The securing of an ample supply of 
food ; the avoidance of chill, damp clothes, night air, and with the 
issue of an early morning ration of coffee or cocoa, with biscuit, is 
about all we can do. For operations in malarious countries the 
selection of troops is one of importance, for there is no "seasoning " 
process against paludal fevers ; on the contrary, one attack, in place 
of conferring immunity, predisposes to another. The prophylactic 
use of quinine has not been followed with any success under the 
circumstances mentioned. 

Heatstroke. — Heatstroke is a thoroughly preventable disease ; it 
occurs in two forms, by direct solar heat, and by the effect of a 
heated atmosphere independent of the sun's rays. Against the result 
of direct solar heat a proper protection for the head and body is 
necessary. Marches should not be undertaken in the tropics when 
the sun*s rays are vertically over the head ; the morning or evening 
is the time indicated. If military necessity demands it, it is better 
that men should march at night than that they should be exposed to 
the risks incidental to a mid-day march ; but the fatigue which this 
occasions should not be lost sight of, nor the inconvenience of reach- 
ing a camping-ground or bivouac in the night and darkness. 

On the march the most open order must be maintained. If the 
ranks close up, the temperature in the ranks rises and the air around 
the men becomes loaded with organic impurity. 

The men should march at ease, with as great freedom ol movement 



APPLICABILITY OF HYGIENE TO MODERN WARFARE. 49 

as possible ; their coats, etc., open, and weights they have to carry 
as far as possible reduced to a minimum. ' This lessens the mechan- 
ical work which they have to do and thus fatigue is lessened. Halts 
should be frequent and sufficient, and every advantage taken of any 
shade. 

Some of the symptoms of heatstroke may also be caused by the 
reflected rays of the sun through the orbit when the optic nerve is 
exposed to direct rays of light. 

In the tropics neutral-tinted glasses are frequently worn, and the 
sense of relief and coolness experienced by the wearers tells the advan- 
tage their use affords. They were found effective in the form of 
goggles in the Egyptian campaign of 1882 as protection against 
glare, heat and sand, and thus in warding off ophthalmia. 

If racial prejudices could be overcome there is no doubt that the 
headdress worn by Asiatics would be of immense advantage to 
Europeans when fighting in the tropics, as it affords a coolness and 
protection which the present helmet fails to secure. 

To guard against the effects of indirect heat the most open order 
in camp must be maintained, and when tents are used, only those 
with double flies should be sanctioned for the tropics. The lining 
should be of a pale blue color, as used in the Sepoys' tents in India. 
Men should not occupy the tents at night unless the country is a 
malarious one, and even then a very slight covering will afford pro- 
tection against malaria. Overcrowding is one of the most constant 
and most dangerous factors in the production of heatstroke. 

On the march the early symptoms of heatstroke should be watched 
for and timely aid afforded. The staggering gait, the flushed coun- 
tenance, abnormally frequent micturition and the absence of perspira- 
tion, should at once demand the attention of the surgeon and timely 
aid be afforded. 

Footsoreness. — Footsoreness is one of the most troublesome 
ailments the surgeon is called upon to treat on the line of march. 
The initial hardness of the leather used in the military boot is the cause 
of much suffering. Once the boot is moulded to the shape of the 
foot it does not press unduly, and as regards wear excels any other; 
but this is a comparatively slow process. Greater pliability of the 
material should be aimed at, as well as greater care in fitting the 
foot. The heels should be low and flat, as these have an important 
influence on the rhythm, which in its turn influences the rate of 
speed and lessens fatigue. 



50 NOTTER. 

Camps, 

In war any theoretical ideas of the site for a camp must be aban- 
doned and advantage taken of any position which presents itself. 
So, too, as regards tents. The advancing army in any future Euro- 
pean war must be prepared to bivouac where military exigencies 
require it to halt, and so far as we at present foresee, the transport 
available will not be more than equal to providing provisions and 
ammunition for those in front, and removing to the lines of communi- 
cation or to the base the sick and wounded of the force. On this 
account some sort of light shelter tent which can be readily adjusted 
seems indispensable : one to be carried between every two men, the 

* 

parts being interchangeable. It might also be made so as to afford 
protection against rain, if worn as in the German army in the form 
of a "poncho." 

As regards sanitation, it is useless to attempt much. There are, 
however, two points which should claim the personal attention of the 
surgeon, and these are : 

1. The nature of the shelter provided. 

2. The disposal of excreta. 

So long as men are on the march and are not provided with tents, 
density of population on a given area matters little, but when, how- 
ever, tents are occupied, this becomes an important factor. Whether 
in tents or in civil buildings, any overcrowding is soon followed by 
disease, and the best efforts of the military surgeon should be directed 
to mitigating this error. 

The best kind of a tent is still a desideratum, but the chief points 
to be aimed at are to secure adequate protection from the weather, a 
free movement and interchange of air, a double fly for tents when 
campaigning in the tropics, that the tent should be as light as possi- 
ble, and should not be of too conspicuous a color. 

In malarious countries the soil under the tent should be beaten 
down as far as possible, so as to prevent exhalations from the ground 
and to keep the tent floor impermeable. Temporary drainage should 
also be secured. 

Camp Latrines. — Camp latrines should be placed to leeward of 
the tents and at least fifty to one hundred yards distant. The trenches 
should be deep rather than wide, so that the surface exposed to the 
sun and air may be as small as possible. If the camp is for more or 
less permanent occupation the trenches may be four or five feet deep, 



• • • • *• • ••• 
••••• •••• 

• •• •• •*•• 



* *•••• • • 

•*• •••• •• •••• 



APPLICABILITY OF HYGIENE TO MODERN WARFARE. 5 I 

small quantities of soil being added daily and the trench filled in 
when within two feet of the surface. For merely temporary use all 
trenches should be one foot wide, one foot deep, with a space of one 
foot between each line, the trench to be filled in when six inches 
from the surface. 

Trenches are only suitable for men in perfect health. For those 
suffering from slight diarrhoea or dysentery it is no easy matter for men 
to get up, say, six or eight times in the night and to grope their way 
to one of these trenches, or to avoid falling into it if they succeed in 
their expedition. A man suddenly attacked with illness could not 
do it; a lazy man would not do it if he could find a handier place 
near by ; both might be excused for refusing to go, say, one hundred 
yards away, under a burning sun, during tropical rain, or with a 
thermometer at or below zero Fahrenheit. 

A latrine barrow would obviate most of the inconvenience, the 
body made of a sort of box, suspended on an iron bar springing from 
the wheel-axle. Such a movable latrine could be easily placed in 
the most convenient situation and emptied as often as necessary ; it 
could be wheeled off to a safe distance and brought back after clean- 
ing and disinfection. No one knows, except they have experience 
of it, what labor and anxiety this question of latrines gives. Fevers 
have been the scourge of armies, and of all armies that become 
stationary for a short time. Why ? Because of this great latrine 
difficulty. To take over houses or civil buildings and to use the 
common privies or water-closets, such as exist in continental towns, 
would be simply to invite the spread of enteric fever, cholera, etc., 
and to avoid the risk which is always present I most strongly 
advocate some system such as I have very briefly sketched out here. 

First Aid. 

In war, with the modern arms of precision and the vast size of 
continental armies, it is impossible to have an adequate " first aid." 
The medical services in all armies are undermanned, and even in 
peace-time it is difficult to find surgeons for the work to be done. 
The cost of medical service is so large in proportion to its strength 
that it is hopeless to expect any increase of that strength. The 
problem then is, how can we best utilize what now exists for meeting 
the exigencies of war ? 

In the British army the Army Medical Staff is divided into two 
branches, executive and administrative. In the former, all wars 



52 NOTTER. 

have shown the officers to be fully competent for the discharge of their 
duties ; the failure, if failure there has been, has happened in the 
administrative grade. In war it is not difficult to obtain a number 
of surgeons well up in their professional work ; but what it is almost 
impossible to form at a short notice is a body of officers thoroughly 
trained in army medical organization according to existing regula- 
tions; men of good administrative ability, having a full comprehen- 
sion of the urgent necessities which spring from modern warfare, and 
with a knowledge how to apply the available medical assistance as 
effectively as practicable whenever and wherever it is most impera- 
tively required. 

To obtain this there should be a large extension of the system of 
personal responsibility, so that the mind may be trained on a larger 
basis, that medical officers in peace-time should have more independ- 
ence and deal within their province with questions of greater magni- 
tude. The defects in the past have been largely in the direction of a 
want of independence on the part of the medical department. They 
have always been fettered by being dependent upon other corps for 
material. No medical department can ever be thoroughly efficient 
which has not actual and absolute control over all elements essential 
to its successful working. 

Owing to the large numbers likely to be engaged in future wars, 
large numbers are likely to be placed hors de combat within a short 
time. The best system of first aid must necessarily be unable to deal 
adequately with such numbers. There is need for the public to 
recognize this fact and so to avoid any outburst of hysterical clamor. 
If nations will make war they must pay the penalty. 

Disposal of the Dead, 

The disposal of the dead on the battlefield is a sanitary question 
of the first importance. In any future war it must be impossible to 
resort to burial as a means of disposal, and it is useless to waste time 
in discussing the best disinfectants to use. Incineration, as practiced 
at Sedan, by pouring tar on the bodies and then setting fire to the 
pile, was a demoralizing and futile process. Burial alone means 
labor, and labor can ill be spared or expended in this direction in 
war. Civilized armies are bound, not only in their own interests but 
of those who inhabit the districts close to the scene of action, to 
dispose of their dead so that they shall be no nuisance. Cremation 
seems the only satisfactory solution of the difficulty. It disinfects 



APPLICABILITY OF HVGIENE TO MODERN WARFARE. 53 

the soil and air, it is speedy, and has no demoralizing efl'ect on the 
morale of men ; it renders the immediate neighborhood healthy for 
the sick and wounded ; it does not defile the ground ; in a word, it is 
cheap and effective and satisfies every sanitary requirement, and it is 
hoped that this method, which has already made some considerable 
progress among the community at large, will in all future wars be put 
into practice, and that the old plan of burial will give place to crema- 
tion as the only safe method for disposing of the bodies of those who 
fall on the field of battle. 



II. 

SECTIONAL MEETINGS. 



THE TRUSTEE OF THE HOSPITAL. 
By Richard Wood, 

President Board of Trustees ^ University of Pennsylvania Hospital, 

He who passes by a hospital and regards it with a casual eye may 
only think of it as a place of pain and suffering, and quicken his pace 
with a shudder. But if, as he looks, its ambulance perchance deliver 
at the door some prostrate wretch, and if pity prompt him to follow 
the pale form to the receiving ward, he will observe with what kind 
and careful scrutiny the patient is regarded by the young resident 
physician ; how every immediate necessity is promptly ministered 
to; how the case is quickly scanned, recorded, placed in its appro- 
priate ward and diagnosed by the skilled medical practitioner or 
surgeon of the visiting medical staff. Having observed the unfor- 
tunate one thus brought under hospital treatment, he will follow its 
processes, will notice their regulated flow from due authority of 
director or superintendent, will note the daily visit of physicians-in- 
chief, the hourly watchfulness of doctors in charge, the constant 
tending of nurses, neat and attentive, the use of clinical thermometer, 
their relief of the person, the giving of ordered diet and medicines, 
the hot applications, the cool, moist bandage, the bath of ice, the 
sterilized knife, the antiseptic dressing. He will note the art, skill, 
precision that runs through all. This art and skill (if the hospital 
be a teaching one) he will see being taught to groups of students 
at the bedside, or in process of transmission to other hundreds 
circling above the clinic bed on the rising benches of the lecture- 
room. After observing these remedial processes he will give an eye 
to the hospital building ; to its spaciousness, clean walls and floors, 
voidness of odor, equable temperature, perfect ventilation, to its 
large, tidy kitchen and busy laundry. In its office he will find 
careful records of the nativity, residence, conditions of life and 



THE TRUSTEE OF THE HOSPITAL. 55 

disease of patients, of numbers received, of cured, benefited or dead. 
These records, and the sight of convalescents lounging on rolling 
chairs in the corridors, will assure him that a good chance of return 
to strength and vigor awaits the poor wretch upon the stretcher 
whom he followed from the ambulance to the hospital. But more 
than a return to outer air will he find provided for in the ministra- 
tions of the hospital. He will see by the bedside the ministers of 
religion consoling the sick and praying for the dying, and upon the 
day of worship will hear in the wards or the chapel songs and 
praises offered to the Author and Disposer of All. The hospital 
will have become to him a place intent with earnest action and 
holy thought — a place whereon might fitly rest the foot of the 
ladder the patriarch beheld, while angels ** ascending and descend- 
ing *' bore the blessings of the life that is, and of the life that is to be. 
Never again will he pass a hospital with a casual eye or a fearful 
tread, for he has learned to know it to be a tree of life, the leaves 
whereof are *'for the healing of the nations.'* 

But our supposed visitor, however much he may have observed the 
hospital and become infused with its movement, will not have seen 
that which gives direction to the movement and force to its action. 
He will not have detected the unseen agent which brings the hospital 
into relation with its surroundings, and gathers together the vital 
forces that quicken and sustain its life ; he will not have seen the root 
of the tree; he will not have seen the governing body of the hospital 
— its Board of Trustees. 

When any competent authority decides a mass of suffering to 
require organization for its relief, and that a hospital must be 
founded, it needs also to decide how to govern the hospital. Hos- 
pitals are commonly founded by authority of governments, national 
or municipal, by church authority, by universities and medical 
schools, and by bodies of charitable people. Military and naval 
hospitals are commonly placed under the administration of the 
respective medical national service. A single officer may be in sole 
charge of a great hospital. During the late rebellion in the United 
States the President of this Congress commanded the largest mili- 
tary hospital in this country — the Satterlee, in Philadelphia. 
National civic hospitals, of which there are several on the continent 
of Europe, are controlled by civic authorities and sometimes cared 
for by high personages. When calling in 1887 at one of the most 
charming and best appointed hospitals in Berlin, I was told it 
received a daily visit from the Empress Augusta of Germany. 



56 WOOD. 

But government hospitals, cared for by slate authority and sup- 
ported by llie public purse, do not most concern a Congress of the 
charities of the world. A very minor number of all hospitals are 
national, and these do not satisfy the innate charitable sense of man- 
kind so fully as others which depend upon the personal aid of large 
numbers of people. 

There must be certain unlikenesses between the boards of hospitals 
organized upon foundations of differing character. The board which 
controls the hospital of a great city almshouse will contain more 
politicians than the trustees of a church hospital, and this in turn 
more clergymen than the management of a hospital founded by 
a medical school or by a body of charitable citizens. 

There wil! probably be differences also in modes of administration. 
A hospital which ia also a great school of medicine and nursing, will 
demand higher intelligence and executive ability in its chief officer 
than a simple infirmary. Indeed, few positions require more tact, 
skill, and special knowledge. Such a hospital must be equipped 
with a larger and more varied staff of physicians, both resident and 
chief, and a greater number of well-trained nurses and of nurses 
undergoing insiruction. 

Tiie purposes of the administration of different hospitals will also 
vary. However much care, forexample, be given to sick paupers, 
it will not be quite of the same kind bestowed upon patients who 
pay $15 to $40 per week for private rooms, 

Tbe difTerences in \.hc frersonriei of the governing boards of hos- 
pitals and the variation in their aims produce diverse methods of pro- 
cedure and conduct of affairs. 

It may be permitted to me, as a citizen of Philadelphia, to select 
four of her chief hospitals as examples of their respective classes, 
viz., the Philadelphia Hospital, the Pennsylvania Hospital, the Hos- 
pital of the Protestant Episcopal Church in Philadelphia, and the 
Hospital of the University of Pennsylvania, Nor let it be, by this 
Congress, thought unfitting to set forth examples from Philadelphia. 
We meet to celebrate the discovery of a New World, Of this New 
World, Philadelphia, beyond all olhers, is the Historical City, the 
home of the Continental Congress and of Washington; the spot 
whereon was brought into form and being the idea of constitutional 
federated liberty, which is the type of modern republican life, and 
which caught from the pious founders of Pennsylvania the thought 
that all men are equal before the law in person and in conscience. 



THE TRUSTEE OF THE HOSPITAL. 57 

Not alone to republican life, but to all life, however governed and 
organized, to men everywhere has Philadelphia presented an unique 
and precious example ; an example that should not be lost to a Con- 
gress inspired by charity. Her founder was the Columbus of a new 
civic polity — a polity resting on charity. And every subsequent 
explorer along all the coast and capes, along all the lines and 
turning-points of polity has but sought what William Penn realized, 
the ideal and prayer of humanity — peace. Unarmed, her inhabi- 
tants came among savages and dwelt with them without thought 
of harm. Nature seemed to sympathize with the affections of men. 

The winds with wonder whist, 

Smoothly the waters kiss'd, 

Whisp'ring new joys to the mild ocean, 

Who now hath quite forgot to ravej 

While birds of calm sit brooding on the charmed wave. 

Life proceeded in this vein for seventy years. The Philadelphians 
freely shared with all honest men the blessings which it brought. 
Multitudes came to partake of them, and with the multitudes came 
the light of common day and common life, and with these a great 
almshouse infirmary — the Philadelphia Hospital. 

The Philadelphia Hospital, 

This hospital is the oldest in America, save the Hotel Dieu of 
Montreal and perhaps some Mexican hospitals. It has become 
famous in several particulars. In it poetry makes Evangeline find 
her dying lover. In it probably originated the gratuitous giving of 
professional service in the public institutions of America — a ques- 
tionable good. In it originated the clinical instruction of this 
country in obstetrics. In it Doctor Gerhard in 1836 first clearly 
established the distinction between typhus and typhoid fever, and 
also reduced the mortality of mania a potu 50 per cent by a new 
treatment. Its staff has been enriched by the famous names of 
Doctors Physick. Chapman, Hodge, Pancoast, Agnew, and Gross. 
Its great copper roof, by an act that outdid the carrying away the 
gates of Gaza by Samson, has, by one of its political superin- 
tendents, been stolen and put into his pocket, a feat accomplished 
by substituting for the copper a tin roof, selling the former as old 
metal and pocketing several thousand dollars by the trick ; this and 
like performances finally providing the superintendent with free 
lodging in jail. 



58 WOOD. 

It has also became a very great hospital. Speaking in round 
numbers, it treats annually 10,000 cases, a tenth of whom are insane. 
From its earliest days (with some intermissions) instruction in the arts 
of healing has been given in it. In 1845 its amphitheater was the most 
capacious and finely arranged in the country, and capable of seating 
from seven to eight hundred persons, " and for over sixty years it had 
been continuously " (I quote the words of Doctor D. Hayes Agnew) 
" the great clinic school of the country, annually opening its exhaust- 
less treasures of disease to crowds of educated, zealous inquirers after 
medical knowledge." In this year an untoward event brought all 
this magnificent instruction to a close. 

Let us inquire what was this event, and examine of what sort was 
the governing body of the Hospital that abolished this great clinical 
school. From and after 1781 the almshouse and its infirmary (the 
Philadelphia Hospital) were under the direction of the guardians of 
the poor of the city of Philadelphia. These guardians from 1803 to 
1854 were a body of thirty or more, elected directly by the popular 
vote of the corporation of the city of Philadelphia and of the corpo- 
rations of the adjacent districts or liberties. They were therefore 
directly subject to the changes of political sentiment and the schem- 
ing of the lower orders of politicians, and little stability and perma- 
nence could be expected in their plans and systems. It is therefore 
not a little remarkable that they permitted the administration of the 
Hospital to rest for so many years in the hands of a medical board, 
composed of gentlemen who acted as volunteers, without pay, and 
therefore in some sense in a spirit of independence. This striking 
fact can be most easily accounted for by the eminent character of 
these gentlemen. 

Indications of restlessness with the medical board are not wanting 
in the history of the guardians. Trouble culminated on June 30, 
1845. The resident physicians were boarded at the table of the 
steward. On this day at dinner a cockroach, attempting to run 
across the table, was indecorously smashed upon it. Thereupon the 
residents demanded to be transferred to the table of the matron. 
Their demand was refused ; they resigned unanimously, and were 
dismissed. The medical board tried to adjust differences and failed. 
The guardians determined to abolish the board — a board "com- 
posed of the ablest men in their various departments on the conti- 
nent." Thus were the doors of the Philadelphia Hospital, as a school 
of instruction, sealed for nine years. Its government was placed in 
the hands of a chief resident physician with three consultants. 



THE TRUSTEE OF THE HOSPITAL. 59 

In 1854 the city and adjacent districts were consolidated. The 
guardians were reduced in number, but still elected by direct popular 
vote. Many abuses seem to have existed during the administration 
of the board thus elected. It has passed into familiar speech and 
printed history as the " board of buzzards." 

In 1859 the board of guardians was purged by the Legislature of 
Pennsylvania. It was reduced to nine members, three appointed by 
the district court, three by the court of common pleas, and three by 
the common council of Philadelphia, one every year for three years, 
and in case of vacancy the appointing powers were to fill such 
vacancy. The new board consisted of the most respectable and 
intelligent gentlemen in the community. They rescued the Hospital 
from the vortex of politics, dispensed with the office of chief resident, 
and re-established the control of the medical board. As a result its 
mortality diminished 25 per cent, and it again became " the great 
clinical school of the country." Government by this board continued 
twelve years. 

In 1 87 1 the Legislature increased the board to twelve members, 
who were to be appointed entirely by city councils and none by 
the courts. Political influence became much stronger than in the 
previous board, — the theft of the copper roof was accomplished, but 
the fame of" the buzzards " was not attained. 

In 1887 the Legislature reorganized the whole government of the 
city of Philadelphia by an act known as the Bullitt Bill. This act 
removed from popular election the members of various executive 
boards managing public affairs, and gave the power of appointing 
these boards to the mayor of the city. The idea was that the mem- 
bers of these boards would feel responsibility more keenly when 
directed to one man, than when diffused among a multitude of 
voters, and that the people could better hold the mayor responsible 
for good government than the members of a score of boards. 

It seemed that a case had arisen in which concentration of power 
in the hands of one man would work advantage to the people. The 
guardians of the poor were therefore abolished and a department of 
the city government created entitled the department of charities 
and correction. It consists of a president and four directors, 
appointed by the mayor and subject to removal by him. These 
gentlemen are practically out of the range of politics. They are a very 
intelligent and devoted body, who work without compensation. 
They weekly inspect the Almshouse and the Hospital and maintain 



6o WOOD. 

them in a very creditable condition. Their annual expenditure for 
these purposes is about $700,000. They appoint the superintendent, 
nurses, and all subordinate officers ; also the 42 doctors who now 
compose the medical board of the Hospital, and the corps of resident 
physicians numbering 16, the latter under civil service rules. Their 
medical, surgical and nursing service is of a high order, and there 
are no stray cockroaches to threaten the existence of a magnificent 
clinic. 

Passing from the Almshouse Infirmary of the city we come to 
consider 

The Pennsylvania Hospital, 

This hospital was founded in 175 1, largely through the efforts of 
the celebrated Benjamin Franklin. It was designed to be the hos- 
pital of the province of Pennsylvania, — **for the relief of the sick 
poor and the care of lunaticks." ** The increase of poor diseased 
foreigners and others, settled in the distant parts of this province, 
where regular advice and assistance cannot be procured, but at an 
expense that neither they nor their township can afford," is among 
the reasons given for establishing it. 

The opening words of the preamble to the act authorizing the 
hospital, ** Whereas the saving and restoring useful and laborious 
members to a community is a work of public service, and the relief 
of the sick poor is not only an act of humanity, but a religious duty," 
have a curious likeness to the kindly and shrewd nature of the author 
of Poor Richard*s Almanac. It is as if it were said, the state ought 
to aid to restore the sick to health because it is humane to do so, 
and because, when in health, they can pay taxes or work for others 
who so pay. In these thoughts lie the germs of state aid to 
hospitals. 

The act incorporated the contributors of the Pennsylvania Hospital 
and permitted any one to be a member who contributed ;^io. It 
authorized the contributors to elect twelve managers and a treasurer; 
to make laws for the hospital, provided they be not repugnant to the 
laws of England, and to hold real estate of a yearly value of ;^iooo ; 
and it also ordered the provincial treasurer to pay ;^200o to the 
contributors for the erection of a building whenever a like sum was 
in hand as endowment. The board of managers still acts under the 
original charter granted by the Provincial Assembly. 

It has contained a long succession of men among the bestf and 



THE TRUSTEE OF THE HOSPITAL. 6 1 

noblest of the community, many of them descendants of the founders 
of the commonwealth, or of those closely affiliated with them. There 
has grown around this hospital and its board a sentiment which 
touches on the romantic, — a sentiment composed largely of love 
untouched by any fear of abuse of trust or misapplication of funds. 

The board of managers conducts three large hospitals, one of 200 
beds for the sick and two for the insane (one male and one female), 
of a joint capacity of about 450 beds. Its yearly expenditure is 
about $300,000, its income from endowment being about $60,000. 
In the year it last reported upon there were treated in the hospital 
for the sick 2170 patients, and its percentage of deaths (deducting 
51 who died within 24 hours after entering) was 5.94. Its^^r diem 
cost for each patient was $1.36. It has treated in all 128,000 
patients, of whom 82,000 were cured and 21,000 improved. 

The Pennsylvania Hospital was " one of the first, if not the first, 
to adopt the enlightened " system of Pinel. One pure and distin- 
guished man, Dr. Thomas S. Kirkbride, presided as officer-in-chief 
over its two hospitals for the insane for 42 years. The managers meet 
monthly. They are divided into twelve committees of two each, one 
of which visits each of the hospitals once a week. 

Among the various committees of this board is a medical com- 
mittee, consisting of the president of the board and the three senior 
members thereof, whose duty is to meet and confer with a similar 
committee of the medical officers of the hospital, upon any subject 
which they may wish to present to the board for its consideration 
and approval ; this committee reports to the board at its stated meet- 
ings any matters that have been before it, with its approval or disap- 
proval as the case may be. This is a most important committee. It 
touches the very core of the usefulness of the hospital. The care 
with which it is constituted shows its importance to be appreciated. 

** Unity of executive control means efficiency of management.'' 
Hospitals form no exception to the rule " that those are best quali- 
fied to conduct a business successfully who are best acquainted with 
its requirements." 

The relation between the managers of a hospital and its medical 
staff should be almost, though not quite, that of partnership : a part- 
nership between those who best understand the material and business 
questions to be dealt with, and those who are skilled in ailments and 
remedies. It is a relation in which each side should carefully weigh 
what the other thinks, and each should have a fair conception of the 



62 woon. 

value of the other's opinion. The managers should consult the staff, 
for example, on the construction of wards and matters of hygiene, 
and, speaking broadly, the staff should respect the views of the man- 
agers touching certain methods of medical and surgical praclice. 

The managers of the Pennsylvania Hospital have balanced these 
questions evenly, but have not shrunk from the responsibility of iheir 
position. They have not been men who would fail to urge even upon 
a renowned professor new methods of practice of acknowledged and 
proved value, and they have been known to forbid to a distinguished 
doctor the use of a fad to which he had become addicted, — I mean 
poulticing with earth. 

A neglect of some of these simple thoughts has resulted in secur- 
ing for the capital of France one of the most cosily and least healthy 
of all recent monumental hospitals, as a careful authority tells us. 

It need hardly be said that a large dispensary and a fine clinic 
have always been maintained by the Pennsylvania Hospital ; to be a 
teacher in this clinic has been, and perhaps still is, to hold the blue 
ribbon of American clinics. 

The Hospital of the Protestant Episcopal Church of Philadelphia 
was chartered in 1851, for the declared charitable objects for which 
hospitals usually exist, and also " to provide the instruction and con- 
solations of religion, according to the principles of the Protestant 
Episcopal Church, for those who are-under the care of the institu- 
tion." 

Every person contributing at one time a sum not less than fifty 
dollars is entitled to vote al the annual election for managers. The 
board of managers consists of twenty-four communicants of the 
Protestant Episcopal Church in Philadelphia, one-third being clergy- 
men, in addition to the bishop of the diocese, he being ex officio 
president of the board, which body, during a vacancy in the episco- 
pate, is entitled to choose one of its own number president. The 
managers are chosen so that eight are subject to re-election every 
year. Seven members for ordinary business and thirteen for other 
affairs are a quorum. The treasurer is not a manager. The man- 
agers appoint each year a medical board, which takes entire medical 
care of the patients and control of the nurses and attendants. 

The bishop of the diocese appoints a chaplain to celebrate divine 
worship in the chapel and to minister to the sick in the wards and 
at their homes. No other religious ministrations, more in accord 



1 



THE TRUSTEE OF THE HOSPITAL. 63 

with the conscience of the patient, are prohibited. Every business 
meeting of the board is opened with '* collects from the book of 
common prayer, or a form of prayer provided by the Bishop." 

The most prominent committee of the managers is that of ar- 
rangements and buildings. It is chosen by ballot and consists of 
not less than seven managers. Its duty is to take care of the Hos- 
pital building and grounds ; also " to consider and take action sub- 
ject to the order of the board, in regard to all matters affecting the 
management or interests of the Hospital "; provided no debts be 
incurred on contracts made without the previous sanction of the 
board. 

The visiting committee of the board is composed of one clerical 
and two lay members, who each serve six weeks, except one of the two 
laymen chosen on the first committee of the year, who serves only 
four weeks, his place being supplied by a layman from the committee 
next in order. The term of service of this layman is six weeks. At 
the end of this term his place is supplied by a lay member of the 
following committee, and thus a connection is established between 
the committees throughout the official year. 

This Hospital has been one of best repute in Philadelphia. It is a 
•model among church hospitals. In 1892 the daily average of 
patients in its wards was 207, and 23,028 patients were treated in its 
dispensary. Its total cost of maintenance was $95,646.33. Its 
revenues are largely drawn from the numerous congregations of 
the Episcopalians of the diocese, and it is a favored recipient of the 
bounty, legacies and memorials of the rich men of that denomination. 

The Hospital of the University of Pennsylvania 

belongs to that University. It is not governed directly by the 
trustees thereof, but by a board of managers composed as follows : 
The provost of the University, ex officio] the director of the Hos- 
pital, ex officio; four of the trustees of the University; four of the 
medical faculty of the University ; three of the medical alumni of 
the University; nine representatives of contributors; four repre- 
sentatives of the board of women visitors — twenty-six persons in 
all. There is also a board of twenty-four women visitors, four of 
whom are represented on the board of managers. These appoint- 
ments are either made by, or subject to, the approval of the trustees 
of the University. 

This organization is complex, but has preserved the control of the 



64 WOOD. 

Hospital in the University, and has also been found sufficiently elastic 
to interest the benevolent community in its support and several 
influential people in its management who have no other connection 
with the University. 

Under this management the Hospital has obtained very satisfac- 
tory buildings, and endowments which yield $30,000 a year, and has 
been able to expend $80,000 per annum in maintenance. It treats 
over 1300 cases in its beds and about 8000 in its eleven dispensaries. 
It maintains an active training school for nurses, and affords bedside 
and clinical teaching to 800 medical students. 

The distinctive features in this management are the majority of 
physicians in the board, and the large body of women visitors. Both 
seem good. The first secures a close relation between medical and 
business interests, giving to the former the preponderance which is 
fitting in the hospital of a medical school. Experience has proved 
women visitors invaluable in household affairs, in the training school 
and among the nurses. Their organic connection with the board of 
management has greatly facilitated internal good government and 
economy, and aided the general administration to attain its deserv- 
edly high repute. 

What, that touches the Trustee of the Hospital, are we to learn from * 
these four brief naratives ? Mainly these things : that the door of 
a municipal hospital should not be ajar for a political trustee ; that 
the faithful trustee gathers about himself general love and respect ; 
that a trustee should be diligent and have much personal knowledge 
of the affairs he administers ; that he should exercise good discretion 
in the appointment of medical officers, and should listen carefully to 
their views in much that concerns the business he conducts ; that he 
should remember final responsibility rests upon himself, even in 
medical administration, and that he should not permit this to fall 
below standards of excellence approved and generally accepted ; that 
he will find comfort and aid from associating women in his labors. 
Finally, we may learn how great sympathy and material support are 
at the command of the good trustee. 

There is among the uninstructed a horror of the hospital. The 
ignorant imagine the sick there to be at the risk of untried remedies, 
to be the subject of experiment because poor and treated freely. 

The trustee who promptly pays the bills of a hospital will have 
done something to dispel this illusion. Men appreciate the honest 
payment of bills, and confidence given for one reason spreads like a 
beautiful vine and envelops all. 



THE TRUSTEE OF THE HOSPITAL. 6$ 

The hospital deals with life and death, and its trustee should feel 
himself to rule and give direction in the constant presence of the 
Eternal, that all he does or permits to be done should be done pains- 
takingly and with an honest conscience. So will he evoke the deli- 
cate sentiments of men, and command the generous forces charity 
places at the disposal of suffering. 

This charity has been ever-existent Though greatly developed 
by Christianity, it has other parentage as well. It is indeed true 
its strength has been most exhibited among modern Christian 
nations — that the hospital revenues of Great Britain and Ireland 
(for example) are ;^ 1,340,744/ 1/3 — (this Congress should thank 
Henry C. Burdett for these figures) — but it is also true that remotest 
ages, that temples of Egypt, cities of Greece, certain emperors of 
Rome, that the Buddhist, the Saracen and the Crusader, the fire- 
worshiper and the Aztec, the Hun and the Frank and the Saxon, 
tell the tender story of love for and organized care of the sick. 

• 

Discussion. 

The Chairman. — I will say that I saw this paper when it was in 
the rough, and my comment on it to Mr. Wood was that I thought 
his declaration that the trustees should have a say-so in the methods 
of medical and surgical treatment in the hospitals would be likely to 
produce some criticism, so far as I know anything of the nature of 
doctors who attend hospitals. Mr. Wood had it that in all methods 
of treatment the Board should have control, but after listening to me 
he interpolated the word *' certain *'; I said they might interfere in 
** certain " methods. It is a very responsible matter for trustees to 
interfere in such a matter, although — as Mr. Wood says — it has 
been done. A physician in one of the prominent hospitals in Phila- 
delphia, a surgeon, acquired the idea that dressing wounds with fresh 
earth was the proper way to treat them, and he urged it in all kinds 
of wounds and all sorts of operations. Of course the trustees were 
right in preventing this, as we know. But how do the trustees know 
how to put their finger on and interfere, except by the information 
that they obtain from some other doctors ? They do not get that 
information out of the depths of their internal consciousness, nor 
probably by studying up the latest records in bacteriology and 
surgery. Now, whenever you have one set of doctors coming to a 
board of trustees in order to explain to them that another set of 



66 WOOD. 

doctors is doin^ wrong, or one particular doctor in the hospital is 
doing wrong, and asking the board of directors to interfere in that, I 
think you all can see that it is a very difficult task that they have 
undertaken. I do not think I should lay it down as a general rule, 
as Mr. Wood has done, that it is the duty of the Board to look after 
the practice of the doctors and keep them straight. 

Mr. C. C. Savage, of New York. — As a trustee of a hospital, I 
want to ask one single question : Who is responsible for the care and 
management of the hospital ? The trustees or the physicians? If 
the trustees are responsible for it, then they must have supreme 
authority over it, and the doctors themselves must be subordinate to 
the trustees, otherwise we have confusion and lack of discipline. 
Now take the hospital with which I am connected, the Demilt 

• 

Dispensary, where the physicians nominate the physicians to the 
board of trustees. We should not hesitate one moment if a doctor 
came before us that we did not approve, to reject him, even on the 
nomination of the medical board, and we sometimes take the liberty 
of changing the views of the medical board. I believe, sir, that the 
lay management of a hospital does most effective work, provided 
the board of trustees is not too large. 

Mr. Arthur Ryerson, of Chicago. — As president of a hospital, 
I am very much interested in the question of the duties of the trustee. 
I think there is one very clear principle that governs the whole 
thing : the government must be in the hands of a board of trustees, 
but having appointed a medical board, the only correct rule is to let 
the medical board run the medical affairs ; and so far as I am con- 
cerned, that is a position I have always taken. 

Now there is another question in regard to this matter ; it is a much 
more practical question here in Chicago, and if any one can throw 
light on it I shall be very glad to get it, and that is this : ** How to 
get a good, active board of trustees of a hospital, and after having 
gotten a board, how to get work out of them ? " I think you will 
find the great difficulty in Chicago is to get men of this kind ; our 
men are very busy, and it is almost impossible to get an active work- 
ing board of trustees. I should like to have some of our friends from 
the East, particularly from Philadelphia, throw some light on this 
question. I know in Philadelphia they do not have so much trouble, 
and I should like to know how to get an active working board of 
trustees. 



THE TRUSTEE OF THE HOSPITAL. 6/ 

Mr. H. C. Burdett, of London. — I should like to say that there 
is no doubt that this question of tl;e relations of the medical staff to the 
governing body is of the essence of the whole spirit upon which the 
administration of any great hospital is conducted. If these relations 
are not sound the whole institution must suffer, and ultimately fall 
into mismanagement. Now I began my experience in hospital 
administration before the days of trained nurses. In the hospital of 
which I was governor it used to be the common practice for the mem- 
bers of the medical staff who met in the wards, to go together into the 
nearest corner and hold a medical board meeting. While we found 
at that time, as representing the lay administration, great difficulty in 
getting proper discipline and proper attendance from the medical 
staff. And after, in these latter thirty years, considering this ques- 
tion very fully, and being acquainted with the systems in force in all 
countries, I have come to this conclusion, that it is desirable, as the 
last speaker said, that you shall have a medical board, and that all 
medical matters shall be relegated to that board. If the trustees, or 
the lay governing body, have medical questions to deal with, it is far 
wisei and better for them to send these questions to the medical 
board and to get the opinion of that medical board in writing, as a 
whole ; because if a medical man cannot stand and is not prepared to 
stand or fall by the judgment of his colleagues, it is perfectly certain 
that he is an undesirable member of any medical staff. On the other 
hand, there are no men and no class of workers in hospitals to whom 
the whole institution is more greatly indebted than to the medical 
board, and I think they are entitled to the independent position 
which an independent board gives, and I believe that to be the true 
solution of all the difficulties relating to the administration of ajiospital. 
With a lay governing committee it must necessarily have a large 
medical staff. 

On the question which the last speaker raised, viz., how are you to 
get a good board of management and to secure the individual attend- 
ance of that board, I have a word to say. It seems to me that the 
greatest and the most valuable gift which any man or woman can 
give to hospitals, or to any other public institution, is the gift of 
personal service, and I venture to say as a stranger in Chicago, and 
I hope in saying I shall give no offense, that this is a question 
for the churches ; that if Chicago, with its ever-growing, increasing 
prosperity, finds that the doctrine of personal service is not yet 
popular among its citizens, I say it is the duty of the churches of 



68 WOOD. 

this city to preach the privilege of personal service, to drive that 
privilege home into the heart of every man and woman in the city ; 
because I know from my own experience, from the experience of one 
of your own millionaires, a great man, who is now dead, but who was 
a personal friend of my own, and who gave enormously to charity, 
who told me this — and it is a word that I wish might reach the heart 
of each man in Chicago — "I never knew what was the worth or 
the value of the privilege of money until I learned to give and to 
give largely to good objects." Now what better object can you have 
than to take an active part in the administration of a great medical 
charity ? I do not think there is a better work in the world, and I 
hope that the difficulties you have here will be overcome. They are 
not confined to Chicago, unfortunately; we have the same difficulties 
in London. But still these difficulties are overcome, and there are 
institutions where there is an esprit which you can feel when you enter 
the doors, and where the privilege of personal service is a real living 
force, which every man and woman in that hospital or that institu- 
tion feels and is moved by, and delights to serve under. That is 
the true spirit ; and if once you could get that spirit anywhere— »and 
until you get that spirit you should never rest — you will not have to 
lament a large board with small attendance, but you will have, as you 
have in many cities now, thank God, a competition in good works for 
the privilege of serving on your hospital boards, and for the privi- 
lege of giymg a litde of the time, which means money to every citizen, 
to the good work of administrating charity. 

Mr. C. C. Savage, of New York. — The question was asked as to 
the way to get a good board. I believe the best way is to first avoid 
ex-officio. members, although I am one myself; and second, to elect 
for a term rather than for life, and when any member of a board has 
ceased by reason of other duties or other interests to do his duty, 
drop him off from the board without regard to who or what he is. In 
other words, keep your board constantly fresh by new blood, and I 
believe in that way a hospital or any charitable institution can be 
maintained in vigor, and only in that way. 



MEDICAL STAFF AND GOVERNING BODIES. 69 



THE RELATIONS OF THE MEDICAL STAFF TO THE 
GOVERNING BODIES IN HOSPITALS. 

By Edward Cowles, M. D., 

Superintendent t McLean Hospital^ SomervilUy Mass, 

In the organization of human society the strong and self-support- 
ing must take care of the weak and dependent. Among the noblest 
motives of humanity is the love that protects the weakness of infancy, 
sickness, age and infirmity. In the same spirit the Christian world 
has built its hospitals out of the love of man for his fellow-men. 

But the hospital is no longer almost solely the refuge and the 
hardship of the poor ; it affords superior care in sickness for all. 
Modern science is so elaborating and refining its methods that many 
things are done for the cure of disease and the amelioration of human 
suffering which can be done only in hospitals. With more com- 
plexity of manipulation in the art of medicine, special conditions for 
its practice have become necessary. The training of women as 
nurses has aided largely in the attainment of better methods by the 
precision of nursing care. 

It has come to pass, therefore, that the salient facts of the present 
time in the history of hospitals are, the building of many small hos- 
pitals, the appreciation of their value to every community, and their 
increasing influence in teaching the gospel of health. Every such 
hospital becomes for its locality a school of health; it is an educator 
of all who have to do with it ; every physician is trained by it, and 
every woman is a better nurse. In the end, according to Havelock 
Ellis, every physician in the country should be attached to a hospital, 
and every person should be living within the district of an institu- 
tion of health. It is safe to say that the time will come in our country 
when a local hospital, if only the smallest cottage that can be fitly 
used, will be accounted the need and demand of every thriving com- 
munity, and that it will be supported by the people whom it serves. 
In the more complete national care of those interests in which the 
guardianship of life is concerned, these hospitals will become so many 
centers of sanitary control in a way never before possible. This 
means the increasing of the sum of human happinesss, and involves 
the highest physical, intellectual, and moral development of the 
nation. 



70 COWLES. 

Il is tlie glory and the hope of modern philanthropy that it is 
learning the principle of prevention, and to know that moral weak- 
ness, sin and crime are so largely maladies which spring from bodily 
ill being. We know that the initial conditions of diseases of mind 
and morals, aa of diseases of the body, are often caused by offenses 
against the laws of health. Knowledge of the causation of disease, 
which teaches the means of prevention, is the most helpful aid to the 
social economist, whose doctrine is thai public health is public 
wealth. In a broader socialism it is the highest philanthropy that 
promotes a general knowledge of the laws of life which must be 
obeyed to cure both physical and moral ills. We are sharing in our 
time in a wonderful awakening, in which there are the strongest 
forces at work in the union of science and philanthropy. 

The hospital has always been regarded as embodying the spirit of 
the Good Samaritan. ,It is an H6tel Dieu, and its administrative 
care has been held as a sacred trust. In the present uplifting of hos- 
pital work toward its larger sphere, those who maintain the existence 
of the hospital and have the keeping of the greater interests now 
centered in il are charged with a greater and more sacred trust. 

The relations {to the hospital and to each other) of the sick, the 
greater public, and those who govern, administer, and serve in it, are 
very complex. Important among these are the relations of the med- 
ical staff to the governing body. But these are conditioned by a 
proper conception of the hospital — its character as an institution. Its 
usefulness depends upon a proper organization, in which certain 
fundamental principles should be supreme which form the natural 
laws of such institutions. Departures from these principles become 
inherent weaknesses that are obstructive of usefulness, or mar the 
harmony without which the best work cannot be done. Upon (he 
basis of a sound organization, the various elements fall into their 
natural places and are easily co-ordinated. For these reasons the 
hospital has a vital character of its own, and for the present purpose 
il is needful to consider three elements prominent in such institu- 
tions: — I, the hospital itself; z, the governing body; and 3, the 
medical staff. 

1. The hospital itself. The business of managing a hospital is the 
same, in principle, in a small hospital as in a large one. It has to be 
learned like any other special business, and governing bodies need 
the knowledge that comes only by experience. Hence the import- 
ance of correct principles. It is easy to go on when the beginning is 




MEDICAL STAFF ^ND GOVERNING BODIES. /I 

right, but difficult to change a faulty system once established. These 
many new hospitals now building are practically, in many cases, new 
ventures by inexperienced organizers of such work. For every new 
one a compilation of by-laws and rules is made from those of exist- 
ing hospitals, with the inherent faults. It is often that new ideas are 
added that seem expedient but end in trouble and disappointment. 
There are two primary sources from which trouble and failure are 
likely to come. These are either faults of the system, which even 
good people cannot get on with ; or faults of individuals under a 
good system. It has been known to happen that when the organi- 
zation is correct and individuals are at fault, the governors have tried 
to remedy matters by changing both the individuals and the system. 
Faulty systems sometimes seem to work well, but that is only a proof 
of exceptional goodness of individuals ; it is often at the cost of trials 
and sacrifices of faithful hospital officers whose lives are hard enough 
at the best. 

A fundamental principle is that the benefits of the hospital belong 
to the greater public, of which the sick who are immediately con- 
cerned are the representatives. It is through the work done for 
them that the great principle of preventive medicine gains its results. 
A sound administration of hospital work promotes the greatest 
good of the greatest number. This indeed is the function of the 
hospital as a health station and a school of health. Every oppor- 
tunity, consistent with the first duty to the sick, for the improvement 
of professional knowledge and skill of physician and nurse should 
be utilized for the advancement of the greatest good. But the 
interest of the sick man, who intrusts himself to the keeping of the 
hospital, is still paramount ; any interest, personal or otherwise, that 
conflicts with this primary principle must be subordinated to it. 
This applies to all hospitals, whether those largely endowed, with 
histories of great work done, as by pure charities, or the many newer 
and smaller ones that must be supported largely by those who use 
them ; or those attached to medical schools for the use of clinical 
teaching ; or corporate institutions for patients of the private class. 

The business of the hospital should yield as its product the 
greatest remedial good that can be gained from the investment made 
in it of capital and service. This means the furnishing of the best 
available service for the sick, and that it is legitimate to improve 
the skill and value of that service for the larger benefit of humanity. 

The hospital, as a place for the conducting of its business, is also 



72 COWLES. 

the habitation of its beneficiaries and of those who do its work. It 
has, as a fundamental principle, an integral character, — a precisely 
defined individuality. It has a peculiarity not commonly recognized : 
while it conducts a business^ it is the home of those who live in it. II 
exists as a family and as an organic unit in the social order. As a 
social unit, its inner life, in its order and discipline, should be com- 
plete within itself, and have a properly respected head, on the basis 
of the family principle. 

The management of a hospital is often likened to a business, such 
as that of a manufactory or a mercantile house. It is more than that 
by having a different human element in it ; the special work of the 
hospital is done by a family, and should be governed with due 
regard for its domestic unity. The competent head of the house- 
hold should have training and capacity for conducting the business, 
and have sole charge of all administrative affairs, under the direction 
of the governing body. 

2. The governing body has its attitude to the hospital plainly 
indicated by the two general principles above stated. It has the 
responsibility of medical and other appointments, which should have 
due regard to the special prerogatives of family headship. It fixes 
responsibility definitely upon the superintendent by requiring of him 
the selection and nomination of all his assistants ; to hold him 
responsible for all that happens he should have a fair chance to pro- 
tect his responsibility. This is the true principle ; and then if there 
is failure it is the fault of the individual and the remedy is plain. 
The functions of the governing body are legislative, in making 
proper regulations and maintaining them through an executive head 
or agent; they 2s^ judicial, in cases of appeal from those exercising 
its delegated authority ; and there are the functions relating to the 
subsistence of the hospital. 

The governing body of any hospital is solely responsible for the 
presence of any patient admitted to its keeping, whether *' free " or 
" private." It is responsible for his proper care and for his discharge 
at a fitting time, in all of which it may act upon the recommenda- 
tion and advice of the medical staff. It is responsible for affording 
all the requisite conditions, appliances, instruments and service to the 
best of its ability. Failure in efficiency, as of instruments or nurses, 
who are virtually skilled instruments, are administrative faults, and 
should be referred to the executive disciplinary head. 

In direct relation to the medical staff, the governing body has the 



MEDICAL STAFF AND GOVERNING BODIES. 73 

Special duty of not only providing the best available professional 
service for the sick in its keeping, but of so enlisting the continuance 
of that service as to promote the increase of the skill that is only 
gained by experience. The governing body should also seek to 
enhance the benefits of this service to the sick by any other legiti- 
mate means that lead to scientific advancement in medicine and 
surgery. 

In the interests of the sick and of promoting in the largest way 
the efficiency of the hospital, the trustees may properly stimulate 
that interest in the work, on the part of the medical staff, that tends 
to the increase of its zeal and efficiency. Here is to be applied the 
principle of conservation of valued. In accordance with a funda- 
mental law in the social order in the struggle for existence, every 
individual should have a wholesome sense of duty to fulfil his per- 
sonal obligations to those having claims upon him. His charity 
should not begin at the hospital nor be given solely there. The 
laborer is worthy of his hire. Fortunately for the hospital and its 
governing body, it is incidental to professional service in it that such 
service increases the skill of the physician, and has a reflex value to 
him in increase of reputation and the productive power of his labor. 
This is good for the hospital, for himself, and for the betterment of 
his usefulness to society at large. 

The governing bodies in hospitals have been finding increasing 
difficulty in the questions arising from the necessity of accommodating 
the principle just stated to the traditions of the charitable institutions in 
their keeping. These difficulties have been formulated in the ** pay- 
patient" question, and are being solved in many directions by a 
change of policy in this matter. 

This question is on the issue as to whether it is equitable for self- 
supporting people to be treated in hospitals upon payment for board 
and nursing care, and make no compensation for the professional 
service as they would do in their private homes. This recent period 
in the evolution of hospitals will doubtless be reviewed as one of 
transition. There is now forthcoming the evidence that appears to 
throw light upon the obscurity as to the equities of this troublesome 
question. It is not to be expected, perhaps, that governing bodies 
can yet see quite clearly the way to properly adjust all the interests 
involved, however legitimate each may seem. But the new condi- 
tions must be studied as they arise, for they appear to be leading by 
their very force as facts to a solution of the problem. 



74 COWLES. 

The great institutions in the large cities, with their splendid endow- 
ments, honorable records and traditions as pure charities, are coming 
to hold an exceptional position, by the minority of their number, in 
the now rapidly lengthening list of hospitals. 

It is to be said for the great hospitals that they make a large 
return to. the medical staff for the professional service rendered, and 
that appointments to such service are sought by men of the highest 
ability, and are accounted as having a definite and well-defined 
value. The conditions are such that all concerned, including the 
greater public, are benefited by the association, as has been set 
forth already. But the discussion of the question for its present 
bearing is best directed to the conditions of the new order of hos- 
pitals, — those that are being built to meet the wide-spreading sense 
of their value, and are developing in the profession at large the 
special skill that modern medicine and surgery require for the 
common heed. 

It can hardly be questioned, in the new status of hospitals, that 
their common use by self-supporting people demands a proper 
co-ordination of the interests of patients, hospital, and physicians 
alike, on the broad principle that equity in the exchange of values 
most soundly promotes human progress. It is interesting to note 
that the facts as they stand appear to be illustrating the law of social 
evolution that mutual interests finally adjust themselves on an equita- 
ble basis. The common arrangement in many of these smaller hos- 
pitals is that the leading local physicians are appointed to the staff 
for attendance upon hospital beneficiaries, but that any reputable 
medical man of the town has the privilege of attending private cases. 
Thus comes quite nearly true, in that locality, Havelock Ellis's dictum 
that every physician in the country should be attached to a hospital. 
Many among the larger towns and smaller cities in New England 
could be cited in proof of this. 

Now there are a number of obvious truths to be noted in these 
circumstances, omitting for the moment the philanthropic motives in 
the exercise of which the medical profession takes reasonable pride. 
The governing body in such a hospital distributes the privilege of 
attending the sick as generally as possible, its special obligations to 
beneficiaries being fulfilled by appointment of the best service for 
them. All these privileges are generally acceptable to physicians. 
There is no clinical teaching, and little addition to local professional 
reputation, from the appointmen| alone. A physician will treat a 



1^ 



MEDICAL STAFF AND GOVERNING BODIES. 75 

private patient in the hospital whom he could not afford to send 
there and deprive himself of a fair honorarium. The hospital needs 
all the board money from such patients it can get, to aid in its sup- 
port. The patient gets superior attendance in the hospital. In fact, 
the more the hospital is used in this way, the better it is for every- 
body. It is exactly for this reason that all are agreed, in every 
community, that a hospital is a good thing ; and it is found to be 
comparatively easy ^ have one, now that there are trained women 
for the managing and nursing. 

It seems perfectly evident that these things all tend to bring it to 
pass that serious medical and surgical and contagious cases will be 
treated commonly in local hospitals. It seems equally obvious that 
the " pure charity *' principle, applied to every such hospital, would 
be adverse to this new and natural movement in the direction of 
higher sanitation and prevention. It is by the recognition of the rule 
of equity in the exchange of values, in compensation for service 
rendered, that these governing bodies are in an important way pro- 
moting the growtbof these hospitals. The more valuable the hospital 
service can be made to the physician, the better he can afford to 
educate himself to a fitness of qualification for it ; the more completely 
the "pure charity" principle is carried out, the fewer hospitals, or 
the less the physician can afford the increasing cost of acquiring his 
profession. 

The discussion of this principle of the conservation of values may 
be left here with the question as to how far it is reasonable, in the 
broadest view of the interests of human progress, to apply it to the 
great charitable institutions. 

3. The medical staff may now be considered as to its relations to 
the governing body in a hospital. Its environment being so fully 
defined in the foregoing discussion, its place in the matter is easily 
found. 

The medical staff does its duty to humanity as its special honor, 
in contributing out of what it has to give, its share of service for the 
common weal. The physician visits the hospital, prescribes and 
directs, and applies his skilled manipulations. He responds to the 
call of the governing body, with advice to the best of his knowledge, 
in all that touches the welfare of the sick ; but whatever control he 
exercises in certain special details, it is delegated authority, and the 
responsibility for all executive acts rests upon the trustees, whose 
prerogatives must therefore be respected. Every patient, " free " or 



76 MERKE. 

"private," is a part of the hospital household, and all failure 
executing the physicians' prescriptions and the like are adm 
faults, and should be referred to the executive disciplinary head. 

The physician may give his services to the suffering poor ; he may 
seek at the hands of the governing body, service in a hospital which 
is a pure charity, and accept as equivalent the reflex benefits to him- 
self (and future patients) of experience and increase in skill and 
reputation; or the opportunity for clinical teaching which may be 
jusdy claimed of every hospital beneficiary when not harmful ; or in 
the new order of hospital work, the physician may equitably receive 
compensation from those whose ability it is, and pride it should be 
to make fair return for value received. 

These principles, essential to a sound organization, will guide to a 
proper adjustment of the relations of the medical staff to the hospital 
and to its governing body. 



UEBER DIE VERWALTUNG VON KRANKENHAUSERN. 



Virwalttingi- DiT, 



H. Merke, 

stadliickrn KrankiH 



" Das Wohl dea Kranlcen ist das hochste Geseiz," so sollte, in 
geringer Abanderung eines bekannten Ausspruchs, das Motto lauten, 
das Uberdem Eingang eines Krankenhauses zu prangen hatte, um 
anzudeuten, dass von diesem Gesichtswinkel aus alle Einrichtungen, 
die ein Krankenhaus aufweist und alle Massnahmen, die in einem 
solchen, in welcher Richtung auch immergetrofTen werden. betrachtet 
und auf ihre Glile bin gepriifl werden miissen. 

Nach zwei Seiten bin bekundet sich nun vornehmlich die Sorge 
fiir das Wohl des Rranken im Krankenhause und zwar einmal in 
Bezug auf die directe Pflege desselben, wie sie in seiner Wartung 
und Behandlung zu Tage trilt — also die rein urztliche Thatigkeit — 
das andere Mai mehr indirect durch die Fiirsorge fur alle die Ein- 
richtungen und Veranslaitungen, die nothwendig sind, um den 
vielseitigen Bediirfnissen eines Krankenhauses, die doch schliesslich 
immer wieder nur im letzlen Grunde dem einzelnen Kranken zu 



Gute kommen, Rechnung zu tragen — und hie 
des Krankenhauses ein. 



t die Verwallung 



k, 



UEBER DIE VERWALTUNG VON KRANKENHAUSERN. TJ 

Gross sind die Aufgaben, die der arztlichen Thatigkeit, wenn 
irg^end sonst, grade im Krankenhause gestellt sind, gross aber auch 
und eine voile Menschenkraft in Anspruch nehmend diejenigen, die 
der Verwaltung in demselben barren. Denn wenn bier auf der einen 
Seite mil der Fiirsorge fiir das Wobl der Kranken weise Sparsamkeit 
gepaart sein muss, die es verhindert, die vorbandenen Mittel fur 
Unnotbiges und Unzweckmassiges zu verwenden, so muss anderseits 
aucb grade eine umsicbtige Verwaltung danach streben, alle Fort- 
schritte und Errungenscbaften der Tecbnik wie der Hygiene fiir ibr 
Gebiet nutzbar zu macben, d. b. den immer weiteren Ausbau des- 
jenigen Tbeils der Gesundbeitslebre anzubabnen, den wir die 
Hygiene des Krankenbauses nennen. 

Sind es doch fast alle Zweige der Verwaltung, in denen diese 
letztere ibre Tbatigkeit entfaltet : nicbt minder in der Nabrungsmit- 
telversorgung, bier Hand in Hand gebend mit den Forderungen des 
Arztes, die Krankenverpflegung betreffend, wie in der Desinfection 
und dem "V^scbereibetriebe, wo sie die Gefabr der Weiterverbreit- 
ung und Uebertragung von Ansteckungsstoffen vorzubeugen bat, in 
der gesundbeitsmassigen Bebeizung und Liiftung der Krankenraume 
sowobl, wie der Arbeitsraume, in denen das Arbeitspersonal bescbaf- 
tigt wird. 

Allein es bandelt sicb bei der Verwaltung eines grosseren Civil- 
krankenbauses — und auf ein solcbes bezieben sicb die folgenden 
Ausf iibrungen bauptsacblicb, wabrend sie die Militairbospitalersowie 
die dem mediciniscben Unterricbt ausscbliesslicb dienenden Kliniken 
ausser Acbt lassen, — es bandelt sicb also bei der Verwaltung eines 
derartigen Krankenbauses nicbt allein um die bisher aufgefiibrten 
Gesicbtspunkte, die icb, weil wie mir scbeint bisber zu wenig beriick- 
sicbtigt, absicbtlicb in den Vordergrund gestellt babe, sondem ebenso 
massgebend ist die ricbtige Organisation der Verwaltung, die es 
ermoglicbt, dass bei dem ganzen grossen Betriebe einer Anstalt ein 
Zusammenstoss von Sonderinteressen vermieden wird, die einzel- 
nen ausf iibrenden Orgarie, sowobl von arztlicber wie von beamteter 
Seite, gleicbmassig zusammenarbeiten und so das Interesse der 
Anstalt wie das der Kranken nacb jeder Ricbtung bin gewabrt wird. 

Wobl lassen sicb allgemeine Grundsatze fiir eine derartige Organi- 
sation aufstellen, die stricte Durcbfiibrung derselben jedocb in 
jedem Einzelfalle zu verlangen, ware, wie jeder Scbematismus, 
grundfalscb, denn diese Organisation muss sicb ricbten nacb den 
lokalen Verbaltnissen, der Grosse, der Bauart und den besonderen 



78 MERKE. 

Zwecken der einzelnen Anstalten. Hier das jedesmal richtige zu 
treffen ist jedenfalls eine der Hauptaufgaben einer gut geleiteten Ver- 
waltung. 

Dieses vorausgeschickt, tritt nun zunachst die Frage entgegen, 
wer an der Spitze der Verwaltung einer solchen grosseren Anstalt 
stehen soil, eine Frage die heute noch, wie vor Jahren, wenigstens 
bei uns in Deutschland immer eine brennende ist und deren Beant- 
wortung, je nach der Stellungnahme, ja fast mochte man sagen, 
nach dem Stande des mit der Losung dieser Frage Beschaftigten, 
im heterogensten Sinne ausgefallen ist. Hie Arzt, hie Verwaltungs- 
beamter, so lautete unH lautet noch heut das Feldgeschrei, sobald 
dieser Gegenstand zur Discussion steht. 

Betrachten wir, bevor wir uns uber die vorliegende Frage aussern, 
wie Staat und Gemeinde sich derselben gegenaber bisher verhalten 
haben, so finden wir, dass man die Losung derselben auf vier ver- 
schiedenen Wegen versucht hat: man betraute entweder eine aus 
Mitgliedern der vorgesetzten Behorde bestehende Commission mit 
der eigentlichen Administration und liess die Kassen und Oecono- 
miesachen, sowie die Bureaugeschafte von einzelnen Beamten, die 
eine untergeordnete Stellung einnahmen, bearbeiten, wahrend die 
Aerzte einfach auf die Behandlung der Kranken angewiesen waren, 
oder man stellte einen Arzt oder einen Verwaltungsbeamten an die 
Spitze der gesammten Anstalt, oder man theilte die Leitung des 
Krankenhauses zwischen einem Verwaltungsbeamten und einem auch 
mehreren Aerzten, die einander coordinirt waren. 

Von dem ersteren Modus der Verwaltung des Krankenhauses 
durch eine Commission, ist man wohl liberall zuruckgekommen und 
zwar mit voUem Recht ; denn ein erspriessliches Wirken, ein freu- 
diges Schaffen, eine voile Hingabe an die Aufgaben einer Kranken- 
hausverwaltung ist dort nicht zu erwarten, wo fast jede personliche 
Initiation gehemmt wird und wo die Priifung der in einem Kranken- 
hause stels neu auftauchenden Bediirfnisse in den Handen von Per- 
sonen liegt, die, dem eigentlichen Krankenhauswesen mehr oder 
weniger fernstehend, naturgemass ein geringeres Verstandniss fiir 
dieselben besitzen, ganz abgesehen davon, dass durch eine derartige 
Einrichtung die ganze Verwaltung eine ungemein schwerfallige wird. 

Die zweite Modalitat, die Stellung eines Arztes an die Spitze der 
Gesammt- Verwaltung eines Krankenhauses, ist an verschiedenen 
grosseren Krankenhausern durchgefiihrt und erfreut sich speciell in 
arztlichen Kreisen einer grossen Beliebtheit. Unser Urtheil hier- 



UEBER DIE VERWALTUNG VON KRANKENHaUSERN. 79 

iiber, wie iiber den dritten Modus, einem Verwaltungsbeamten allein 
die Gesammtverwaltung eines Krankenhauses anzuvertrauen, werden 
wir weiter unten angeben. Was endlich die Theilung der Verwaltung 
zwischen einen Verwaltungsbeamten und einem Arzte betrifit, so hat 
dieses Princip in Berlin beispeilsweise scwohl bei dem Koniglichen 
Charit^ Krankenhause, wie in den 3 Stadtischen allgemeinen Kran- 
kenhausern Anwendung gefunden in der Weise, dass dem Verwal- 
tungs-Director mehr die Leitung der eigentlichen administrativen 
Angelegenheiten, den arztlichen Directoren (im Charity Kranken- 
hause ist nur ein arztlicher Director vorhanden, wahrend in den 
Krankenhaiisern der Stadt Berlin je zwei, und zwar einer fiir die 
innere, der andere fUr die chirurgische Station angestellt sind) 
speciell die Vertretung der arztlichen Interessen obliegt. 

Von vorn herein miisste es als das Natiirlichste erscheinen, dass 
in einem Krankenhause ein Arzt an der Spitze der Anstalt steht ; 
handelt es sich ja doch um ein Haus fiir Kranke, und deren nachste 
Bediirfnisse kennt und versteht naturgemass am besten der Arzt. 
Dies Raisonnement ist richtig, sofern es sich unmittelbar um den 
Kranken selbst und dessen Wartung, Pflege u. s. w. handelt; hier 
soil und muss dem Arzt vollstandig freie Hand gelassen werden, 
hier darf kein Fremder, kein Laie, und ware sein sontiges Wissen 
und Konnen auch noch so gross, storend eingreifen wollen. 

Anders aber gestaltet sich die Sachlage,wennessich um diegrosse 
Menge alles dessen handelt, was zwar nicht unmittelbar zu dem 
Kranken und seiner Pflege in Beziehung steht, aber doch alle die 
Vorkehrungen und Einrichtungen in sich begreift, die nothigsind, 
um fiir das Wohl des Kranken nach jeder Richtung hin ausgiebig 
Sorge tragen zu konnen, d. h. um die eigentliche Verwaltung. 

Bereits im Eingange dieser Besprechung haben wir kurz die Auf- 
gaben, welche der Verwaltung eines Krankenhauses zufallen, ge- 
streift und wollen an dieser Stelle, wo die Frage zur Entscheidung 
steht, wer die Verwaltung des Krankenhauses fiihren soil, noch 
einmal auf dieselbe zuriickkommen. 

Betrachten wir noch einmal kurz die Aufgaben, welche der Ver- 
waltung eines Krankenhauses zufallen. 

Sie hat in jeder Beziehung das Interesse der Anstalt zu wahren 
und dasselbe nach aussen hin zu vertreten. Sie hat darauf zu ach- 
ten, dass die allereigentlichste Bestimmung eines Krankenhauses 
fur das Wohl der Kranken zu sorgen und Alles aufzubieten, was 
zur Pflege und Wiederherstellung derselben nothwendig ist, nie aus 



80 MERKE. 

falscher Sparsanikeit ausser Acht gelassen wird. Sie ist ferner verant- 
wortlich der vorgesetzten Behorde fiir die richtige Fuhrung der 
nothwendigen Biicher und Acten, sowiefiireinezweckentsprechende 
Finanzwirthschaft in der Anstalt. Hier hat sie veraltete Verwaltungs- 
maximen zu beseitigen, den Geschaftsgang nach Moglichkeit zu 
vereinfachen, fiir aiisserste Klarheit und Uebersicht Sorge zu tragen. 

Hierzu kommt die Beaufsichtigung des wirthschaftlichen Betriebes 
der Anstalt in der Oekonomie sowohl wie im Waschereibetriebe, 
auf die wir im Speciellen noch am Schluss dieser Abhandlung 
zuriickkommen werden. Femer ist es Aufgabe der Verwaltung, die 
bestehenden hygienischen Einrichtungen voll auszunutzen, nicht vor- 
handene zu schaffen, fehlerhafte zu vervollkommnen. 

Wie sie aus der wissenschaftlichen Forschung die Nutzanwendung 
fiir die Praxis ziehen soil, so wird sieauf ihrem Gebiet durch scharfe 
Beobachtung neue Fragen aufwerfen, deren Beantwortung wieder der 
Wissenschaft zufallt, ein Wechselverkehr, der beiden Theilen zu 
Cute kommt. 

Treten wir nun der Frage naher, ob ein Arzt ausschliesslich der 
Leiter eines Krankenhauses sein sol], so mtissen wir auf Grund der 
obigen Auseinandersetzungen dieselbe verneinen. 

Die reinen Verwaltungsangelegenheiten liegen dem Arzte, seinem 
ganzen Bildungsgange entsprechend,vollstandig fern, nirgends hatte 
er in seiner Vorbildung Gelegenheit, sich mit ihnen zu beschaftigen, 
tiefer in sie einzudringen, ein Verstandniss fiir dieselben zu gewin- 
nen. Ein neues Feld, das ihm vollstandig fremd ist, und dessen 
Studium Zeit und Miihe voraussetzt, miisste er bearbei ten, werth voile 
eigene Errungenschaften in seiner Wissenschaft far das Gemeinde- 
wohl ungeniitzt lassen und das AUes zu dem einzigen Zweck, um im 
giinstigsten Falle annahrend auf diesem Felde das zu leisten, was ein 
Anderer, der das Verwaltungsfach zu seinem Beruf gewahlt hat, 
ohne sonderliche Miihe schafft. Soil man wirklich eine wissenschaft- 
liche Capacitat auf dem Gebiete der Medicin dieser Wissenschaft 
entreissen, nur um aus ihr einen mittelmassigen Verwaltungs-Be- 
amten zu machen ? Ich meine nein ! 

Die zweite Frage wiirde lauten, ob es sich empfielt, einen Ver- 
waltungsbeamten an die Spitze eines Krankenhauses zu stellen. 
Auch hiergegen wiirden wir uns erklaren, da durch eine derartige 
Einrichtung besonders bei den Aerzten nur zu haufig der Glaube 
hervorgerufen wird, als wiirden, bei einer scheinbaren Collision der 
arztlichen Interessen mit denen der Verwaltung, erstere den letzteren 



ij«eai 



UEBER DIE VERWALTUNG VON KRANKENHaUSERN. 8 1 

hintenangesetzt. £s hat zudem stets eCwas Missliches fiir sich, wenn 
in einem Krankenhause der Arzt unter einem Nichtarzte fungiren 
muss. 

Ich wurde deshalb dafiir plaidiren, dass die Leitung eines Kran- 
kenhauses einem arztlichen Director und einem diesem coordinirten 
Verwaltungsdirector zu Ubertragen ist. Freilich sind an den letz- 
teren ganz besondere Anforderungen zu stellen. 

Zun'achst genilgt es durchaus noch nicht, dass derselbe in irgend 
einer anderen Verwaltung Tuchtiges geleistet hat, um ihn fiir einen 
derartigen Posten als besonders geeignet erscheinen zu lassen, 
vielmehr muss der Nachweis gefordert werden, dass er ausserdem 
bereits in gleichen Anstalten sich diejenige Summe von Kenntnissen 
und Erfahrungen angeeignet hat, die vorhanden sein muss, um in 
diesem eigenartigen Verwaltungsfach erspriessliches leisten zu 
konnen. Ferner muss er unbedingt auf dem Gebiet der Hygiene, 
und speciell der Krankenhaushygiene, gut durchgebildet sein, da 
beziigliche Fragen, wie wir oben auseinander gesetzt haben, fast 
tSglich in der verschiedensten Form und Richtung an ihn heran- 
treten. 

Der Preussische Minister fiir das Unterrichtswesen hat erst neu- 
erdings wieder in Anlehnung an einen friiheren Eriass die Behor- 
den aufgefordert, geeignete Beamte aus den einzelnen Ressorts auf 
langere Zeit zu beurlauben, um ihnen die Moglichkeit zu geben, sich 
an einem der verschiedenen hygienischen Institute, wie sie bereits 
die Mehrzahl unserer Universitaten besitzt, in dieser Wissenschaft 
wenigstens allgemeine Kenntnisse zu erwerben ; ebenso muss auch 
von einem Beamten, der die Leitung eines Krankenhauses Uberneh- 
men soil, eine genauere Kenntniss derjenigen Zweige der Hygiene, 
die speciell auf das Krankenhauswesen Bezug haben und auf die wir 
oben bereits hingewiesen haben, gefordert werden. Man konnte 
hier den Einwurf erheben, dass es geniige, wenn der arztliche Leiter 
der Anstalt die nothigen hygienischen Kenntnisse besitzt und dass 
auf ihn in dieser Beziehung recurrirt werden konnte, allein, dem ist 
entgegenzuhalten, dass auch in rein wirthschaftlichen und techni- 
schen Fragen, in denen der Arzt in der Natur der Sache noch nicht 
so bewandert sein kann, wie der Verwaltiingsbeamte, mehr und 
mehr die hygienische Seite derselben, und zwar mit Recht, in den 
Vordergrund tritt und dass auch hierin der Beamte auf Griind einer 
entsprechenden hygienischen Vorbildung im Stande sein muss, 
selbststandig zu urtheilen und Verbesserungen zu schaffen. 



82 MERKE. 

• 

Mit einem solchen Maass von Kenntnissen ausgeriistet, wird es 
dem Verwaltungsbeamten nicht schwer fallen, bei dem ihm coordi- 
nirten arztlichen Leiter der Anstalt sowohl, wie bei dem iibrigen arzt- 
lichen Personal sich diejenige Achtung zu erwerben, die unbedingt 
nothwendig ist, um gemeinsam und in gegenseitiger Unterstiitzung 
im Interesse des Krankenhausesr, d. h. im Interesse der Kranken 
zu schaffen und zu wirken. . 

Die vorsteheden Ausfiihrungen beziehen sich, wie bereits erwahnt, 
auf grossere staatliche oder communale Krankenhauser, fur die 
Krankenhauser kleinerer Gemeinden, die gewohnlich nur uber 30- 
50 Betten verfiigen, mogen dieselben nicht in jeder Bezlehung 
zutreffend sein; insbesondere wird man bier schon aus Sparsam- 
keitsriicksichten in der Hegel die Leitung der Anstalt in die Hande 
des behaiidelnden Arztes legen, was bei der geringen raumlichen 
Ausdehnung solcher Krankenhauser, der nur auf das Nothwen- 
digste sich beschrankenden, haufig recht primitiven Einrichtungen 
und dem leichteren Ueberblick Uber dieselben auch als ausreichend 
erscheinen muss. Immerhin sollte hier wenigstens der Verpflegung 
der Kranken, die fiir gewohnlich in den H'anden eines Oberwarters 
ruht, sowohl von Seiten des Arztes wie der zustandigen Behordeganz 
besondere Aufmerksamkeit gewidmet werden. 

Wenn ich bisher bei dem Thema iiber die Verwaltung von Kranken- 
hitusern die Personenfrage beruhrt habe, so geschah dies, abgesehen 
von ihrer Bedeutung an und fiir sich, auch besonders einem mir per- 
sonlich geausserten Wunsche entsprechend ; ich will nun noch ver- 
suchen, wenigstens einige Zweige der Verwaltungsthatigkeit kurz zu 
besprechen, eine eingehendere Behandlung verbietet die kurz- 
bemessene Zeit. 

Ein wichtiges Hulfsmittel bei der Krankenbehandlung bildet 
bekanntlich eine gut geregelte Verpflegung der Kranken. Die Ent- 
scheidung dariiber, welche Speisen dem Patienten in den einzelnen 
Krankheitsstadien zutraglich sind, welche nicht, liegt in den Handen 
des behandelnden Arztes, die Sorge fiir gute Beschaffenheit und 
richtige Zubereitungsweise in denen der Verwaltung. In den Ber- 
liner stadtischen Krankenhausern sind fast vollstanding ubereinstim- 
mende Diatvorschriften gegeben, nach denen die Verpflegung der 
Kranken, sowie des Personals etc. zu geschehen hat, und von denen 
ein Exemplar in der Anlage a hier beigefiigt ist. 

Ohneauf die Einzelheiten der Verpflegung selbst nahereinzugehen, 
mochte ich hier eins der wichtigsten Nahrungsmittel, das Fleisch, 



UEBER DIE VERWALTUNG VON KRANKENHaUSERN. 83 

herausgreifen und (iber die Art und Weise der Beschaffung dessel- 
ben, sowie seiner Aufbewahrung und Verarbeitung in Dauerform, 
wie sie in unseren Krankenhausern geiibt wird, und, wie ich sie 
aus langjahriger Erfahrung heraus als bewahrt empfehlen kann, 
berichten. Die Lieferung fiir den Fleischbedarf des Kranken- 
hauses wird in einer engeren Submission, die unter den ersten 
en gros Schlachtern des Centralviehhofes, von denen bekannt 
ist, dass sie nur Thiere erster Qualitat schlachten, ausgeschrieben 
wird, gewohnlich an den billigst Liefernden vergeben. Die Vor- 
schriften iiber die Qualitat des zu liefernden Fieisches, sowie uber 
die Auswahl u. s. w. der einzelnen FleischstUcke finden sich in der 
beiliegenden Anlage b. niedergelegt. Die Controle dariiber, dass 
das Fleisch in vorgeschriebener Gute geliefert wird, f iihrt der von 
der Stadt Berlin angestellte Director der st'adtischen Fleischschau 
auf dem st'adtischen Central Vieh- und Schlachthof resp. sein Vertre- 
ter, der aus der Zahl der dort fungirenden Thierarzte gewahlt wird. 
Jedes zur Lieferung fiir das Krankenhaus bestimmte Thier wird 
einem dieser Herren lebend vorgefiihrt und zunachst untersucht und 
begutachtet, nicht entsprechendes sofort zuriickgewiesen, darauf 
unter seiner Controle geschlachtet und, falls es nach nochmaliger 
Untersuchung *der einzelnen Theile den vorgeschriebenen Beding- 
ungen entspricht, von dem controlirenden Director resp. seinem Stell- 
vertreter gestempelt " und ausserdem mit einer den Stempel des 
Krankenhauses tragenden Plombe versehen. Durch diese Einrich- 
tung wird die Verwaltung, soweit dies iiberhaupt moglich ist, vor 
einer Uebervortheilung von Seiten des Lieferanten geschutzt. 

Zertheilung des gelieferten Fieisches, sowie Verarbeitung dessel- 
ben zu Schinken, Wurst u. dergl. besorgt ein im Dienste des Kran- 
kenhauses stehender Fleischer; s'immtliche Fleisch waaren, die hier 
consumirt werden, werden von diesem Fleischer hergeslellt, Nichts 
von auswartigen Lieferanten bezogen. Dieser Beschaffungsmodus 
bietet, abgesehen von den pecuniaren Vortheilen, die der Anstalt aus 
ihm erwachsen, die Garaniie, dass nur gesuJides Fleisch in gtUer 
Qualitat zur Wurstfabrikation etc. zur Verwendung kommt, dass 
also auch das hergestellte Fabrikat von ausgezeichneter Beschaffen* 
heit ist. 

Frisch geschlachtetes Fleisch eignet sich bekanntlich nicht zur 
sofortigen Verwendung bei der Speisenbereitung, da es in diesem 
Zustande gekocht oder gebraten hart und zsth wird, man muss das- 
selbe vielmehr einige (6-8) Tage liegen lassen, ehe man es verbraucht . 



Fiir dicsen Zweck sind Aufbewahrungsraume nothig, sogenaonte 
Fleischkammcrn, in denen es die entsprechende Zeit hindurch ver- 
wahrt wird. Vender richtigen Construction dleser Aufbewahrungs- 
raume hangt es wesenllich ab. dass das Fleisch vor dem Verderben 
geschiitzt und in seiner Qualiliit nlchl verschlechlert wird uiid es 
muss deshalb grade in grossen Anstalten, wo grosse Fleischmengen 
vorrlilhig zu halten sind, ein grosser Werlh auf die zweck entsprech- 
ende Einrichtung dieser Kammern gelegt werden. Eins der besien 
Conservirungsmitiei fiir Fleisch ist die Kalte und zwarin Form fort- 
wahrend zugefiihrter kaller. aber auch moglichsl trokner Luft ; es 
wird indess nur wenig Krankenhauser geben, die sicli deu Luxus 
einer Kalllufimaschine leisten konnen und das directe Einbringen 
von Eis in die Vorrathskammern schiitzt nicht vor dem sogenaiinien 
Beschlagen und Schmie rig werden des Fleisches, d. h. vor der 
Ansiedehing und schnellen Verbreiiung von Schimmelpilzen auf der 
Oberfliiche, wodurch eine Enlwerthung desseiben herbeigefiihrt wird. 
Am besten conservirl man das Fleisch, ohne der Aufstellimg mehr 
oder minder kosiapieliger Apparale benolhigt zu sein. nach unseren 
Er/ahrungen in Raumen mit unausgeselzterLurtcircuIation.dieam ein- 
fachsten durch Offenhalten der mit Drahtgaze versehenen Fensierund 
Anbringung entsprcchend grossen angeheizten Absaugescbloten 
erzielt wird, Wande, Decken und Fussbijden miissen so gehalien 
sein, dass sic leichi abgewaschen, desinticirt und die leizteren direct 
entwasscrt werden konnen. !n diesen Raumen werden die Fleisch- 
theile einzeln, so dass sie sich nicht beriihren und in Folge dessen von 
alien Seiten von der Luft umspiiit werden, aufgehangl. Es ist femer 
nolhig, aile frische Schnittfiiichen, sowie al!e feuchte Oberflachen 
des Fleisches sofort mit reinen trockenen Leinentiicheni abzutrock- 
nen. um keine feuchlen NabrbiJden fiir die Ansiedelung von Mikro- 
organismen zu schafiFen ; die zum Trockenreiben des Fleisches 
benulzten Tiicher, sind vorher durch Dampf zu steriiisiren und nach 
jedesmaliger Verwendung zu reinigen, 

Ein unerljissliches Erforderniss fiir jedes Krankenbaus, das immer 
noch nicht geniigend gewiirdigt wird, ist das Vorhandensein von 
genugend grossen zweckentsprechendangelegten und eingerichteten 
Dishi/eclionsvorkeli>u7igen zuni Desinficiren der Krankenwasche 
sowohl, wie der von den Kranken mitgebrachten KleidungsslUcke 
{auf die specitU ein gam besonderer Werth gelegl werden muss) 
und der im Krankenhause benutzien Anziige. Leider tindet man 
auch heute noch selbst in neuerbauten grossen Krankenhausern, wie 



I 



UEBER DIE VERWALTUNG VON KRANKENHaUSERN. 85 

beispielsweise biz vor Kurzem in dem neuen allgemeinen Kranken- 
hause der Stadt Hamburg in Eppendorf zu diesem Zweck Heiss- 
luftapparate, obwohl doch langst durch Robert Koch's grundlegende 
Versuche, die zum grossten Theil in unserem Krankenhause ange- 
stellt wurden, die Unwirksamkeit dieser Art der Desinfection fest- 
gestellt ist. Als bestes und sicherstes Desinfectionsmittel fiir 
Effecten ist stromender Wasserdampf von mindestens 100° Celsius 
Temperatur anzusehen und nur solche Apparate, in denen dieser 
^ur Anwendung kommt, sollten zur Desinfection benutzt werden. 
Die bauliche Anlage soll.derartig gehalten sein, dass eine vollstandige 
Trennung der zu desinficirenden Gegenstande von den desinficirten 
durchfiihrbar ist. Der leichteren und billigeren Dampfbeschaffung 
wegen ist es zweckmassig, sie in unmittelbarer Nahe des Kessel- 
hauses zu errichten. 

Die Desinfection des Verbandraaterials geschieht in kleineren Appa- 
raten ebenfalls unter Verwendung stromenden Wasserdampfes von 
mindestens 100° Celsius, dieamzweckmassigsten in der chirurgischen 
Abtheilung aufgestellt sind. 

Zur Desinfection von Se- und Excreten, haben sich bei uns Koch- 
apparate bewahrt, die sich in einem der Vorraume jedes Kranken- 
saales resp. Pavilions befinden und in denen, bevor man sie den 
allgemeinen Canalisationsanlagen zufilhrt, die Excremente sowohl, 
wie der Inhalt der Spei- und Uringlaser abgekocht werden. 

Was schliesslich den Waschereibetrieb im Krankenhause betrifTt, 
so muss in erster Linie dafiir gesorgt werden, dass das mit der 
Wasche beschaftigte Personal vor Ansteckung geschiitzt und durch 
die bei dem Kochen der Wasche sich entwickelnden Wasserdampfe 
nicht iibermassig belastigt wird. Das erstere geschieht wie oben 
besprochen, durch eine vorhergehende griindliche Desinfection der 
Wasche im Desinfectionsapparate ; die Belastigung durch Wasser- 
diimpfe vermeidet man durch Benutzung hohercontinuirlich mitvor- 
gewarmter frischer Luft versorgter Waschraume, die durch ange- 
heizte Schlote gut und schnell entliiftet werden konnen. Am 
empfehlenswerthesten ist der Betrieb mit Maschinen, wie er jetzt 
wohl auch uberall durchgefiihrt wird. Das Trocknen der WSsche 
in stark erwarmten Rstumen wahrend der kstlteren Jahreszeit ist als 
ungemein schadigend auf die Gesundheit der dabei beschaftigten 
Personen wirkend, was ich aus eigener Erfahrung bestatigen kann, 
giinzlich zu verwgrfen ; an Stelle dessen sind Trockenmaschinen 
(nicht Tirvirs, Schieber zum Herausziehen, welche unniltz Platz 



86 



DOCK. 



wegnehnien und durch ausstrbmende Warme das Bedienun^s-Per- 
sonal beliisligen) in deneii bei sehr reger Ventilation bei ca. 35° R. 
getrocknet wird, zu beschaffen. 

Ich habe in dem Vorstehenden nur vereinzelte Punkte aus dem 
grossen Gebieie der Krankenhausverwaltung cursorisch streifen 
kbnnen, moge das Wenige, was ich geboten und das, zunachst an 
einheimische deuEscbe Verhallnisse ankniipfend und auf dieseBezug 
nehmend, schliesslich wohl audi fiir auslandische zu verwerUien ist, 
freundliche Aufnahme finden, miigen auch speziell die kurze Be- 
sprechung einiger Zweige der Krankenhaus-Hygiene Anregunjj 
geben. sich mehr und mehr mit dieser leizteren zu beschaftigen und 
zu ihrem weiteren Ausbau beizutragen. 



THE RELATION OF TRAINING SCHOOLS TO 
HOSPITALS. 



By Mjss L. L. Dock, 

UHdiHt of Nurses. Tk/ Jah»s Hepliins Hospital. 



The establishment of training schools in America dates back only 
twenty-one years, and the entire modem system of trained nursing, 
beginning with the foundation of Kaiserswerth in 1827. is not yet 
sixty years old, Hospitals, on the other hand, have existed for 
hundreds of years. In this, the present day, training schools are 
numbered by the score, and each year sees new ones opened, as 
one hospital after another falls into line and issues its circular 
announcing that "arrangements have been made to provide two 
years training to women desirous of learning the art of caring for 
the sick." Did the hospital, then, call the training school into exist- 
ence? Strangely enough, it did not, though'the two seem now so 
fundamentally united. The training school idea did not originate 
within the hospital, but was grafted upon it by the eflbrts of a few 
inspired ones outside, who saw the terrible need of the sick, who 
knew the inadequacy of the care they received, and who bravely 
knocked at the hospital doors, first closed, but gradually opening 
more and more widely. 



i9»aBBiBB II ■! 



RELATION OF TRAINING SCHOOLS TO HOSPITALS. 8/ 

The mutual need of one for the other was not, at the outset, 
equally felt by both. The hospital was absolutely necessary to the 
school ; the school was not necessary to the hospital, according to 
the crude and ignorant idea of what was sufficient for the sick, under 
which hospitals had been mismanaged for centuries. Good nursing 
is indeed necessary for the best results and for the fully perfected 
work of the hospital, and it was to this truth that different hon- 
ored members of the medical profession bore witness long before the 
time when the half unwilling hospital accepted the training school 
on sufferance. The first attitude of the school was, therefore, that 
of an applicant, and its work experimental. After a few years trial 
it has so well proved itself that the hospital is now the one to hold 
out inducements, and the consequent growth of the school has been 
so phenomenally rapid as to give rise on the one hand to congratu- 
lations, and on the other to the question : is it built on a strong 
foundation ? 

A study of the present conditions existing between hospitals and 
training schools is at first sight dispiriting. In their relations to each 
other may be discovered a formlessness, a lack of tradition, an adop- 
tion of hasty and tentative methods, and an acceptance of imperfect 
results, for which the training school is often blamed, though much 
of the fault lies with the hospital. But discouragement over this 
state of things, though natural, need not be severe, when we remem- 
ber that the hospital has had hundreds of years in which to develop, 
while the training school has had but little over half a century. 
Medicine is old, while nursing, though one of the most ancient of 
occupations, is .the very youngest of professions. Moreover, on 
closer observation of what seems at first a heterogeneous mass, there 
may be seen in it elements of order and strength and permanence. 
There are three points of view from which the relation of the school 
to the hospital should be considered. The first shows an outline of 
the material and financial connection between the two, and considers 
the value of the school as an economic factor in the history of the 
hospital. The second sees the school as a moral force. The third 
faces the responsibility of the hospital to the school, and the way in 
which the school meets the demands of the hospital. 

The training schools of America may be broadly separated, as to 
their outward form, into two classes : those which are an integral part 
of the hospital, and those which are independently organized and 
attached to the hospital by contract. The first is quite the larger 



88 DOCK. 

class, and in it, with but few exceptions, are found the schools estab- 
lished by those hospitals in which, from their general characteristics, 
one would naturally expect to find expression to some degree of the 
reforming spirit of the times; the private and endowed hospital, 
church, college, or university ; and a small number of municipal 
hospitals. 

The independently organized schools were the pioneers. First in 
the line of advance, they most triumphantly illustrate the moral force 
at work in the development, still rudimentary, of nursing. These 
are the schools which, by the courage and goodness of women pre- 
eminently, have been affixed to those hospitals that need them most 
and want them least — the city or county hospitals, where local poli- 
tics grow at the expense of the neglected sick poor — in all ugliness, 
contemptuous of disinterested work, and hating to be interfered with. 
Individual ability and determination alone have made it possible to 
force the purifying influence of the training school into these places ; 
for it may be safely asserted that in no instance has the political 
element of any municipal hospital ever voluntarily introduced reform 
into the nursing, or yielded to it save oh irresistible pressure brought 
to bear from outside by those who had no political capital to make, 
who feared no one, and who were determined to succeed. 

No stronger contrast could be shown than that between typical 
schools of these two classes : the one established by an enlightened 
and humanitarian hospital — a peaceful existence secured to it; the 
other a pioneer — its position insecure, its history full of exciting 
vicissitudes. In the one instance may be found union in an almost 
complete degree. There may be identity of interests and of aims ; 
a recognition of mutual benefits ; a sense of mutual obligation ; a 
reciprocal feeling of personal pride, admiration and attachment. The 
other is an example of the " incorporated union," which Gladstone 
declares can never become perfect. The training school attached to 
the political hospital can never truly become one with it until in the 
evolution of the civic virtues local politics either change their nature 
or are removed from the field. 

The standard and aims of the school are absurdities to the hospital 
controlled by politics ; the methods and tone of the hospital are 
odious to the school. From first to last its history is one of struggle 
and strenuous effort to obtain decent conditions, to resist degrada- 
tion, and to do good work in the face of obstructions and difficulties 
always great and sometimes enormous. At the same time the line 



RELATION OF TRAINING SCHOOLS TO HOSPITALS. 89 

must be drawn with prudence, for it is in the power of the hospital 
to terminate its agreement, or to make conditions such that it is 
impossible for the school to continue its work. Such a course annihi- 
lates the training school, and shows the bare hardness of the fact, 
once stated, that it is not necessary to the life, only to the improve- 
ment of the hospital. This possible destruction of the school is not 
an imaginary catastrophe ; on the contrary it has occurred in more 
than one instance. As, however, not all political hospitals, even the 
most unscrupulous, are immediately likely to overthrow their train- 
ing schools, and as not all private hospitals realize the ideal, there 
are some advantages claimed by the independent school over the 
others. For one thing, it is possible for it to become (as one of our 
largest schools is at this moment) self-supporting ; always a more 
dignified position than that of being supported, and to be so recog- 
nized. Moreover, it is free to live its own life, uninfluenced by what 
may be cramped and mean in that of the hospital, and to develop 
unhindered in whateverlinesof progress may open up to it. But among 
those which are the personal property of hospitals of illiberal and 
narrow policy, what half-dead training schools we see ! their scope 
and possibilities closely repressed, their educational advantages 
selfishly restricted, their outlook limited and their influence a drag. 
How easily are the rightful claims of the school then sacrificed for 
the benefit of the hospital, and how difficult to defend themselves 
against injustice and even oppression when the relation is only that 
of owner and property. But beyond all this, the independent school 
has this advantage over the other, that the very isolation and diffi- 
culty of its work brings out and strengthens in it those hardy virtues, 
endurance, frugality, self-denial, and courage, which are not easily 
cultivated in a softer atmosphere. 

Of the internal dissensions that sometimes mar the relations of the 
training school and hospital, there are, broadly speaking, two 
sources : one is a weak government of the school itself; the other is 
the failure to separate clearly the medical and the nursing provinces. 

The wide-spread want of a sound conception of the idea of discip- 
line is a direct cause of some of the most unsatisfactory conditions 
existing between hospital and school. The most blurred and waver- 
ing lines in the whole structure are directly traceable to this funda- 
mental weakness. It is perhaps natural enough that the women who 
enter the schools should have rudimentary ideas on the subject, but 
it might reasonably be expected that this imperfection should not be 



go DOCK. 

found in those who undertake to govern them ; yet it is unquestion- 
ably true that in the experience of most schools there have come 
times when it was vividly realized that boards of directors, women's 
committees, and even the medical staff themselves, though all strong 
on discipline as a theory, are as broken reeds when the practical 
question comes up of maintaining it at the cost of some difficulty. 
The organization of a training school is and must be military. It is 
not and cannot be democratic. Absolute and unquestioning obedi- 
ence must be the foundation of the nurse's work, and to this end 
complete subordination of the individual to the work as a whole is as 
necessary for her as for the soldier. This can only be attained by a 
systematic grading of rank, a clear, definite chain of responsibility, 
and one sole source of authority, transmitted in a straight line, not 
scattered about through boards and committees, but concentrated in 
the head of the school as their representative and delegate. They 
cannot represent themselves ; they cannot do her work, nor exert her 
influence. She must do this herself, and there is no danger of mak- 
ing her an autocrat if they will consistently maintain their own just 
and true position, that of wise advisers, or judges if need be. Most 
unsound is the policy of the hospital which habitually interferes in the 
affairs of the school ; and the most undignified expression of weak- 
ness of this kind is that which gathers up from women in training, who 
have not yet proved their merit, opinions, information, or complaints 
upon school or hospital matters. 

Leaving out of sight the dishonorable element in this practice, it is 
at once evident that all discipline must be at an end if authority is 
thus handed over to the ranks ; yet this fatal short-sightedness has 
hampered the work of more than one school. 

To say that there are any lines on which the medical profession 
may not control the nursing world may sound revolutionary. It is 
not so. On the contrary, in the clear perception of what those lines 
are rests the only security for future order and harmony of action. 
It may be claimed that if the military idea is the basis of the school, 
the members of the medical profession being undoubtedly the superior 
officers, should properly control the school throughout its entire 
course, and even in its internal management, and that the whole subject 
of the teaching, training and discipline of nurses should be at the 
discretion of medicine. This might hold good except for one simple 
yet radical point of difference. The private soldier in the ranks and 
the officer in command have the same profession. The officer is also 



RELATION OF TRAINING SCHOOLS TO HOSPITALS. 9 1 

a soldier and knows every detail of the common soldier's work 
and life. The nurse and the physician have different professions. 
The doctor is not a nurse, and only now and then is one found who 
fairly comprehends the actual matter-of-fact realities of the training 
school. On this fundamental difference reSts the claim of the school 
to be ruled, as an educative and disciplinary body, by those of its own 
origin. For another reason the separation of the medical power 
from training school affairs should be rigidly enforced, and that is 
the destructive effect of personal influence on the idea of duty. In 
hospitals about us may be seen the results of giving the hospital staff 
any practical hold over the school. What, for instance, is the conse- 
quence of allowing young internes to choose their own undergraduate 
head-nurses ? The standard of the work is at once lowered by the 
introduction of the personal element. The pupil nurses are exposed 
to the temptation of seeking the favor of individuals. Partizan 
cliques invariably form, whose self-interest may be directly opposed 
to the best interests of the hospital and its pursing work; and promo- 
tion on a true merit-basis is utterly and at once impossible. In the 
struggle against influences of this kind the school is likely to be 
unjustly condemned by the hospital as troublesome. Arbitrary, insub- 
ordinate, its head as the natural enemy of the medical staff; a false 
position into which, by unfairness and jealousy, she is sometimes 
ungenerously forced. 

On one field only does the school properly come under the com- 
mand of the medical profession, and that is in the direct care of the 
sick. Here indeed the command is absolute. The whole purpose 
of the school centers around this point, and the pride of the well- 
drilled nurse is to make this service perfect. 

Now for the first time in the history of medical science can its 
orders be carried out faithfully, fully, and at all hours. The useless- 
ness of expecting such obedience from even intelligent persons who 
have not been trained is well illustrated by the remark of a lady of 
position and education, concerning the orders given her by the 
physician for her child's diet. " I shall do just half of what the doctor 
said," she observed, "as I always make a discount for each doctor's 
own particular fad." 

This obedience to orders, founded on principle and animated by an 
intelligent interest, is the dominant characteristic of the new system 
of nursing, and is the secret of its success in its professional work. 
Without it the most desirable and charming qualities would be 



92 DOCK. 

useless to the nurse; but with it, the value of her practical work to 
the hospital is at once and widely demonstrated. 

There is much evidence to show that the material prosperity of 
the hospital is largely due to the work of the training school. To 
just what extent this is tifie would perhaps be impossible to say, for 
where a dawning rationalism in medicine,, antisepsis in surgery, a 
growing intelligence of public opinion, and trained nursing are con- 
temporaneous, each stimulating and being stimulated by the others, 
no one could candidly ascribe results to one isolated influence. Yet, 
whether it be only a coincidence or not, in this country, at least, a 
definite impetus and advance in hospital work dates' from the foun- 
dation of trained nursing. The testimony received from over forty 
hospitals is unanimous on this point, not one exception having been 
met with. " Our results are better both in medicine and surgery," 
they say; " the work of our hospital has extended in every direction. 
There is a marked diminution of the popular dread of hospitals. 
Private patients come in greater numbers, and many ascribe their 
willingness to enter to the presence of the nurses. The difference in 
the general comfort and happiness of the patients alone would be 
enough, if there were nothing more, to secure the gratitude of the 
hospital to the school, while the difference in the death-rate marks an 
era in the treatment of the sick." 

To illustrate these general statements, the experience of two small 
hospitals, selected at random, may be cited. One, a hospital for 
children, had for years under the old regime the character of an 
orphan's home. Thirty or forty little ones with chronic diseases 
collected in it ; acute or serious cases were rare ; operations infre- 
quent ; public interest was languid. Within three years after the 
introduction of trained nursing, the medical staff* and general manage- 
ment being unchanged, new wards were built, an operating room was 
added, and an active service of acute medical and surgical cases kept 
80 beds constantly filled and constantly changing. The other is a 
hospital for gynecological and obstetrical patients. In former times 
only those applied who had no other resource, and half the beds 
were empty. The nursing was reformed. A few years after the 
change the statistics showed in one year 38 operations and 143 
births ; the same number of years after the change, 144 operations and 
257 births. Such facts show the practical value of the school in a strong 
light, and tend to modify the statement sometimes made by hos- 
pital bbards that the school is an expensive luxury. The difference 



RELATION OF TRAINING SCHOOLS TO HOSPITALS. 93 

made in the value of the hospital as a field for clinical medicine is 
alone sufficient to repay the debt of the school. TJie actual cost of 
the school is not always easy to demonstrate. Hospitals supporting 
their own schools do not as a rule keep separate accounts, and the 
only definite statistics to be found are those of the independent 
schools, which receive so much from the hospital for services 
rendered. The old plan of nursing cost much less than the new. 
Nurses were paid from $12 to $20 a month ; two or three were con- 
sidered enough for 30 or 40 patients, for as they could do but little, 
but little was expected of them. Their lodgings were in any spare 
corner of the hospital, and their table was coarse and cheap. But in 
the race of competition this economical system had to be given up 
for one that would give better results, and the hospitals had to con- 
sider the practical question of how to get their nursing done. To 
secure graduate work would be at this stage an impossibility. The* 
supply is not sufficient ; moreover, the graduate who receives on an 
average of $20 a week at private duty, naturally will not toil for an 
hospital for a smaller sum, unless some inducement is offered, such 
as a position of responsibility, or further training in the line of some 
specialty. Even leaving the money out of the question, it would be 
precarious to attempt the nursing of a general hospital, or even a 
ward, with graduates, for their different methods would produce 
irregularity and unevenness in the work, and their independence of 
the hospital would permit untimely changes and general insecurity. 
The training school offers the hospital the most practicable way out 
of the difficulty. The expenses are undoubtedly large in comparison, 
for while the actual sum paid monthly to the pupils as an allowance 
is, per capita, smaller than that paid the old-time nurses, yet the 
number necessary to do the work according to a revised standard is 
fully three times as large. Moreover, comfortable and healthful sur- 
roundings and proper food are now understood to be necessary pro- 
visions to make for nurses, and finally, some expense must be 
incurred for theoretical instruction, so that the whole difference in 
cost may be roughly estimated as about i to 5. Nevertheless this 
plan offers the hospital distinct advantages. The training school is 
• a flexible instrument, and though more expensive than the old 
method, is less so than graduate nursing would be. The promise 
of an education secures a steady supply of intelligent women, thus 
eliminating all uncertainty on that score. The discipline and strict 
subordination of the school make it possible for the hospital to exact 



94 DOCK. 

from it an amount of work which it would be quite impossible to 
demand from women over whom it had no special hold ; while the 
chain of responsibility and the careful supervision of the school secure 
an average quality of work as good, if not even better than that which 
would be obtained from nurses working merely as employees. 

Practically, then, the hospital secures nursing for $12 a month on 
its pay-roll, which at its market value would bring at least $15 a week, 
while the living expenses are little or no greater in the one case 
than in the other, the cost of lectures and educational appliances 
being the only additional outlay in the support of the undergraduate 
school. There are those hospitals which, in the desire to econo- 
mize, find ways of minimizing cost at the expense of the school. The 
outlay for teaching purposes is cut down, and the number of nurses 
reduced by giving to each the longest possible hours of duty. Yet 
*in comparison with hospitals and training schools in other countries, it 
is gratifying to find how much more generous a spirit is, on the whole, 
shown in those of our own country. Among the foremost there are 
comparatively few, and among the most prominent only one or two, 
that make their nurses a source of revenue by working them outside. 
The returns on this point are .imperfect, yet are sufficient to show 
there are many small hospitals compelled by actual poverty to 
bring in an income from private duty, and others where poverty is 
less evident and where the school is evidently founded on a mercenary 
basis ; while among those that are larger, yet still not in the front 
rank, one reports earnings covering one-eighth of its expenses ; two • 
earn two-thirds each ; three earn one-half each ; while two schools 
report earnings which cover almost the entire cost of their mainten- 
ance and tuition. In other words, these different schools bring in 
incomes varying from $300 to $5000 and $6000 a year. In the two 
latter cases it is quite evident that the schools, besides giving the hos- 
pitals an amount and quality of work which the hospitals could not 
possibly secure if they had to pay for it, really support themselves 
and pay for their own tuition at the same time — a rather remarkable 
arrangement, one must confess, and one which the hospital surveys 
with the utmost complacency, keeping the school in the meantime 
in an attitude of the strictest subserviency, as though the hospital 
were the benefactor and the school the grateful recipient of benefits. 
A survey, then, of the whole subject compels one to believe that 
financially the school is not the debtor of the hospital. Although it 
is costly, yet its economic value is not measured by the dollars spent 



RELATION OF TRAINING SCHOOLS TO HOSPITALS. 95 

upon it. Its part in building up or adding to the prestige of the hos- 
pital IS not computed and paid for, yet It is vast, and has a definite 
money value in the returns of the hospital. 

Of all the attributes of the school its moral strength is the most 
easily demonstrable, and its reformatory work is the part of its whole 
work in which it can most securely stand on its own merits. Other 
forces may seek to divide with it the diminished death-rate and 
better results in medicine and surgery, but the changes wrought in 
the moral atmosphere of the once foul old hospitals we have all 
known of are peculiarly and entirely its own. Those who know the 
internal affairs of institutions are aware that people outside can form 
no idea of what conditions formerly existed within the walls of, say, 
some great city hospital where the city paupers were collected. The 
misery of the neglected sick was one thing, the depravity and moral 
degradation another. The one could be described ; the other was 
indescribable. The badness was worse, even, than the sufferings of 
the sick, for they ended with death. No nurse who has had some 
such hospital service could ever tell all of her experience, yet she has 
gone in and worked through many such places, and they can never 
again return to what they were before. In these old hospitals the 
medical profession labored unselfishly over the diseases of the body ; 
ministers of the church passed in and out and strove with souls ; 
charitable women brought flowers and food and a temporary cheer- 
fulness, but degraded and vile they remained throughout until the 
youth, strength and energy of the training school assailed them and, 
by coming to live among them, transformed them. *' This place used 
to be like hell,'' said an old hospital patient to the newly established 
nurse, ** but now it is like heaven." 

Even among hospitals of the better class have been found many 
where, under an outward appearance of decorum, there was rampant 
a coarse vulgarity, or an utter lack of principle, or a spirit of tyranny, 
from the highest to the lowest. These have presented the most 
difficult and delicate tasks of regeneration, for such evils are subtle, 
resistant, and well organized. Many battles have been fought by the 
training schools against all these hostile forces ; battles of which few 
people will ever know. 'Many victories have been gained, each one 
of which makes the future easier and more promising. Many nurses 
have laid down their health, or their lives, in such struggles, as 
uncomplainingly as the soldier in time of war. 

The last division of my subject, the responsibility of the hospital 



96 DOCK. 

to the training school, and the way in which the school meets the 
demands of the hospital, will be so forcibly treated in another paper 
that it is not necessary to take it up here. It will be shown that the 
whole responsibility of the hospital is to give the school a thoroughly 
good education and time in which to assimilate it. It wilt be shown 
that the shortcomings of the school are largely due to imperfect 
preparatory training, and to the crowding of work and study into the 
short period of two years time. With a fuller comprehension on 
the part of the hospital of the real work and the actual purposes 
and the aims of the training school, and with renewed patience and 
energy on the part of the school, there will gradually die away thai 
mistrust on the one hand, and something like aggressiveness on the 
other, which have marked the relative relations of many hospitals 
and schools, and which are already beginning to disappear. In the 
cordial co-operation of the future, as outlined in the paper mentioned, 
lies the hope of those who are working toward what they know to 
be the possibilities of nursing. 

Discussion. 

Miss Lett, ot Chicago : In regard to the trouble between the train- 
ing schools and the hospitals, I think that the matter of discipUne is 
not clearly understood by the hospital authorities, although, as Miss 
Dock says, theoretically they are willing to preach it but they do 
not care to practice it. And then I think a good deal of trouble may 
come by the selection of a head of a training school. They do not 
take sufficient trouble to get those of experience. To overcomethat 
difhculty, the period of training in our training schools ought to be 
longer than two years ; it ought to be prolonged to at least two and 
a half years. 

Miss Darche. of New York: I merely wish to say thatl think the 
paper is conclusive about matters of discipline. There is only one 
way to settle that, and that is the authorities should put at the head 
of the training department some one they have confidence in. If 
they have not confidence in her, remove her, but let her have the 
management of matters of discipline in her department. It seems to 
me that would settle (he whole matter; if they have not confidence 
in the head, remove her. 

Dr. Hubd, of Baltimore : I am very much of the opinion that there 
is really no division of interest between the hospital and the training 



j^ IS reajiy nu u 



RELATION OF TRAINING SCHOOLS TO HOSPITALS. 97 

school, and I deprecate myself the statement on the part of any one 
that there is. The only object of the hospital is to take care of the 
sick ; the only reason of the existence of the training school is to 
furnish a proper training in taking care of the sick ; there really can 
be no opposition in the ends which both the hospital and the train- 
ing school have in view. I have always regarded it most unfortunate 
that the original training schools were outside the hospitals, and that 
one of those training schools still regards itself as a municipality out- 
side of the hospital, with full authority to criticize hospital methods, 
and to complain of them without making any special effort to better 
them. The attitude of that school has constantly been inimical to 
the hospital with which it is connected. I believe there should be 
the greatest identity of interest between the hospital and the training 
school ; the hospital ought not to ask anything unreasonable of the 
school, and the school ought not to ask anything unreasonable of the 
hospital. My own view is this, that the great difBculty has been in 
not giving enough authority to the superintendent of the nurses* 
training school. I believe it is the duty of the hospital authorities to 
make no mistake in selecting the superintendent of nurses ; and when 
selected, she should have their heartiest co-operation. Allow her 
to carry out her own plans and ideas ; let her select and discipline 
her nurses, and make her responsible for the well-being of the school. 
If she proves to be not the right person, get another ; but do not 
allow the board of trustees of the hospital to interfere in the internal 
management of the training school. For my own part, I believe that the 
hospital and the training school should constantly work together, 
that nothing can hurt the training school without hurting the hos- 
pital, and that nothing can help the school which injures the hospital ; 
and that training school and hospital should go on together. 

The Chairman : I will simply say that if the superintendent of the 
training school is perfect, knowing her own business, and having full 
power of discipline, and is a lady of tact and education, the whole 
business must necessarily be left entirely to her ; that such a woman 
never does have any particular trouble. But I say that such women 
are extremely rare, just as men who are qualified to take charge of 
and command a big establishment are extremely rare. The difficulty 
comes not with getting your theoretical set of rules and regulations 
giving the superintendent of nurses full authority, but it comes 
sometimes when she finds it necessary to discipline some nurse who 
is perhaps attractive in manner and ways, and who is particularly 



98 KURD. 

satisfactory to some of the trustees or to some of the medical staff; 
that nurse appeals — she has been treated with great injustice — and 
the appeal comes to people who do not know anything about the 
matter. 

In my capacity as director of a hospital I have that sort of appeal 
come to me sometimes; occasionally, once in awhile, I think — twice, 
perhaps, I thought — they were a little hard ; but nevertheless the rule . 
of the superintendent of the training school goes with me. And if that 
is not satisfactory, why then we must get another superintendent. 



THE RELATION OF HOSPITALS TO MEDICAL 

EDUCATION. 

By Henry M. Hurd, M. D., 

Superintendent of The Johns Hopkins Hospital^ Baltimore^ Md, 

It is not my purpose to argue the duty of hospitals to promote 
medical teaching. They have always contributed to it, and always 
will, in an increasing degree, as medical education becomes better 
organized and more efficient. The hospital, whether avowedly so or 
not, has always been a school of medicine, sometimes to the few who 
were attending physicians, resident physicians or internes, and some- 
times, and now, I am glad to say, more often, to those who are pur- 
suing medical studies. The relation of hospitals to medical educa- 
tion has been reciprocal for good. Medical teaching has improved 
hospital work, and hospital work, on the other hand, has improved 
medical teaching. Neither* can exist without the other. It is my 
purpose in this brief paper to point out methods whereby hospitals 
can best subserve medical teaching, and to emphasize the duty of 
promoting it. A hospital which does not contribute to the advance- 
ment of medical knowledge, by bringing the results of its investiga- 
tions and experience to the training of medical students, in the plastic 
stage of their education, fails to attain its highest good or to surround 
itself with the brightest investigators. The duty being apparent, to 
point out the best method of attaining the desired end must be the 
sole object of the present inquiry. 

I. Pathological InstiitUes.—F'wsi in importance I would place the 
organization of a good pathological institute in connection with every 



RELATION OF HOSPITALS TO MEDICAL EDUCATION. 99 

hospital. By this I mean much more than an autopsy room and a 
museum for the preservation of morbid specimens. These are valu- 
able, but their work is not of prime importance compared with what 
may be accomplished by systematic investigations in all branches of 
pathological study. Facilities should be afforded for the study of 
every morbid product. There should be opportunities for systematic 
bacteriological examination of pus, serous effusions, the products of 
inflammation, the bodily secretions and excretions, false membranes, 
new growths and the like. The diagnosis of diphtheria and of follic- 
ular tonsillitis, for example, should here be made by cultures, cover- 
slip preparations and the microscope. The different forms of peri- 
tonitis should be differentiated similarly. The effusions of pleurisy 
should be studied bacteriologically to determine the presence or 
absence of the tubercle bacillus. Malarial fever should be differen- 
tiated from other forms of continued fever by the presence of the Plas- 
modium. The micrococcus lanceolatus, otherwise known as the 
pneumococcufi, should be searched for in pneumonia and cerebro- 
spinal meningitis. Such studies are impossible unless rooms are 
provided, specially fitted up with apparatus, instruments and trained 
observers constantly at hand for the purpose. These studies give a 
definiteness to diagnosis by excluding possible diseases of other 
origin, and certainty to prognosis. 

The microscopic study of tumors and new growths while an oper- 
ation is in progress and before its completion is of equal value. 
Three examples drawn from actual occurrences in a Baltimore 
hospital will serve to make my meaning clearer. A patient with a 
suspicious abdominal tumor, presumably malignant, had submitted 
to an exploratory operation, and a frozen section while she was on 
the operating table, and before the operation was completed, showed 
the growth to be tubercular in character. The cavity of the abdo- 
men was drained and washed out with a sterilized salt solution, and 
the patient made a good recovery. A second patient seemed to be 
suffering from a simple abscess of the breast, but a bacteriological 
examination of the contents of the abscess cavity showed that the 
inflammation was tubercular in character, and led to the examination 
of the surrounding tissues, which were found to be filled with tubercle 
bacilli. A radical operation for the removal of these diseased tissues 
then followed, and a condition was found present which justified a 
grave prognosis. In another case a culture made during a severe 
abdominal operation subsequently showed that a chronic peritonitis 




lOO HURD. 

had been caused by a virulent streptococcus, and led immediately to 
the isolation and separate nursing of the patient to prevent the infec- 
tion of the ward. Such instances are of daily occurrence, and the 
wisdom of these expert examinations is fully established by repeated 
experience. 

In dressings, also, subsequent to surgical operations, similar 
sources of infection are revealed by bacteriological examinations, and 
the communication of infection to other patients may be prevented 
by the knowledge thus acquired. This work, while of prime import- 
ance, ought not to impede the true work of a pathological labora- 
tory, which is to study the origin, course and effects of disease upon 
every organ of the human body. Every large hospital ought to have 
a paid pathologist whose whole time should be given to this form of 
study, and he should be provided with a sufficient number of assist- 
ants to do this work thoroughly. Diseased tissues and organs should 
be examined in gross at the autopsy table, and afterwards the material 
should be studied in frozen sections and by hardened specimens. 
Cultures should also be made post mortem of all products of inflam- 
mation, to determine their precise character. These studies clear up 
obscure diagnoses and lead to the more successful treatment of other 
cases. 

2. Clinical Laboratories. — Every hospital ought also to have a clin- 
ical laboratory for blood examination, urinary analysis, the examina- 
tion of the stomach contents, and the examination of feces and sputum. 
The blood should be examined as a matter of routine in all forms of 
wasting disease. The value of the methods of Ehrlich in the differ- 
ent forms of leukaemia is attested daily by practical observation. The 
differentiation of malarial from typhoid or other forms of continued 
fever is frequently only possible when the plasmodium has been 
demonstrated in the blood. The importance of a bacteriological 
examination of cholera-stools for the presence of the comma bacillus 
has been recently demonstrated in the late cholera epidemic in 
Europe. The equal importance of searching dysenteric stools for 
the presence of amoebae coli has been demonstrated many times in 
the clinical laboratory of the Johns Hopkins Hospital during the 
past year. Abscesses in the liver and lungs and one jaw abscess have 
thus been shown to be dependent upon this protozoan. The confu- 
sion which exists in the profession to-day regarding malarial haema- 
turia can only be cleared up by similar expert examinations. In such 
clinical laboratories syphilis often needs to be differentiated from 



RELATION OF HOSPITALS TO MEDICAL EDUCATION. lOI 

tuberculosis by the microscope. In skin affections also, like urticaria, 
favus, the different forms of dermatitis, tinea versicolor and tuber- 
culosis need to be similarly studied. The presence of the otomy- 
cosis aspergillus in ear affections can only be definitely shown by the 
microscope. The tetanus bacillus, the streptococcus of erysipelas, the 
staphylococcus of suppuration, and the pneumococcus of pneumonia 
and meningitis should also be similarly demonstrated when present. 
In no other manner can medical education be made definite and thor- 
ough. The day of theories and brilliant hypotheses to account for 
many of these diseases is past, and demonstration ought to replace 
them. 

3. Operating Rooms. — Every hospital of any size, and especially 
a hospital to which medical students have access, should have surgi- 
cal operating rooms arranged for carrying out a perfect surgical 
technique. Here should be consistent and constant efforts to reduce 
the dangers to patients from the infection of wounds to the minimum. 
These operating rooms should be object-lessons in thorough surgical 
cleanliness. There should be apparatus for hand disinfection and 
facilities for scrubbing and cleansing the hands. Every step in the 
technique of antiseptic surgery should be carefully prescribed and 
followed. It is now evident that infection of wounds does not come 
through the air or from atmospheric conditions, but rather from 
actual contact. Pus-producing germs gain access to wounds at the 
hands of the operator or his assistants, or by infected instruments or 
ligatures, or through infected skin-stitches, or by subsequent dress- 
ings. Hence it is of the utmost importance that the technique pur- 
sued in every hospital operating room be thorough and consistent to 
the end, that every person may know the reason of the procedures 
adopted. Students and physicians should be trained to appreciate 
understandingly what is harmful and to be avoided, and what is harm- 
less and permissible. It may be asserted, with confidence of no suc- 
cessful contradiction, that in the technique of many surgeons unneces- 
sary precautions are frequently taken, and necessary precautions are 
as frequently omitted, from a lack of adequate knowledge of the true 
sources of infection. These can only be adequately taught by bacte- 
riological methods. Ligatures, instruments, bandages, and all forms 
of dressings, should be sterilized in such a way as to meet every 
bacteriological requirement. Cultures taken from the first dressings 
made subsequent to an operation should not grow upon any form of 
culture media. Experiments which have been made in wound infec- 



N^ 



102 HURD. 

tion have clearly demonstrated its sources, and its methods of pre- 
vention. Each operating room should be as carefully arranged to 
carry out antiseptic precautions as the laboratory of the bacteriologist. 
More than this may also be asserted. Every operating room ought 
to pursue careful and systematic experiments upon hand disinfection. 
No one believes that an ideal excellence has yet been attained. These 
fruitful experiments are alone possible in large operating rooms, with 
frequent operations and abundant facilities for carrying on the work 
thoroughly. It is most gratifying to call to your attention the fact 
that two large operating rooms have lately been constructed in New 
York with every facility for this systematic work. If they contribute, 
as they undoubtedly will, to the simplification and perfection of surgi- 
cal technique, their erection will fully justify the outlay, large as it 
may seem to the unthinking critic. 

4. Photographic Rooms. — An equally important part of the educa- 
tional outfit of a general hospital should be a well constructed and 
well arranged room for photogfaphy. Here medical men should be 
trained to do photographic work in the various departments of hos- 
pital service. Each man should be taught the manipulation of cameras 
and photographic plates, and should learn methods of developing, 
printing, enlarging, etc. Photo-micrography has proven a very dis- 
appointing branch .of photography. A poor drawing which accu- 
rately portrays what the observer sees is generally much to be 
preferred to the most finely finished micro-photograph with its 
blotches of color and flattened surface. Not so, however, with what 
may be termed gross medical photography. Its field of usefulness 
is apparently limitless. Many surgical conditions should be photo- 
graphed upon the spot, even while an operation is in progress. The 
rapidity and accuracy with which newly discovered or newly recog- 
nized forms of disease have been made known to the medical public 
are well shown by the disease known as acromegaly. Although this 
disease was first differentiated and described by Marie in 1886, its 
peculiar facies became at once familiar to physicians throughout the 
world by the excellent photographic reproductions which were dis- 
tributed, and to-day it is easily recognized wherever found, by 
medical men who have never been shown a case. In a similar 
manner cases of myxcedema and the various forms of paralysis have 
been accurately portrayed, to the great advantage of the student 
of medicine. Photographs of skin diseases, deformities, muscular 
atrophies and hypertrophies, ulcers, tumors, aneurisms, surgical 



RELATION OF HOSPITALS TO MEDICAL EDUCATION. IO3 

operations, surgical methods and surgical dressings, portray these 
conditions much more clearly and satisfactorily than pages of 
description. In many instances these representations are sufficient 
to enable the observer who has not seen the case, to confirm the 
diagnosis. 

5. Charts and Graphic Representations, Histories, — Allied to 
photography are the various forms of charts and graphic representa- 
tions. These should be made with absolute accuracy and regularity, 
and should form permanent records in the hospital. The same is 
true of medical histories, which ought to be made up daily, at the bed- 
side. Such medical histories should be classified, indexed, cata- 
logued, and rendered accessible, so that any fact of medical interest 
may be referred to at a moment's notice. There should be a medical 
staff large enough to do this work thoroughly well. The influence 
of these careful records upon medical knowledge can hardly be esti- 
mated ; their greater influence in training medical men who are 
connected with hospitals to habits of careful, painstaking, exhaustive 
observation and faithful records of the same is undeniable. 

6. Dispensary Work, — The position of carefully conducted medical 
work in dispensaries or departments for out-patients, in training 
medical men, is well recognized. The patients who present them- 
selves for treatment at these clinics more nearly represent the patients 
with whom physicians come into daily contact than ordinary hospital 
patients. Hence the same necessity in dispensary practice of train- 
ing students in habits of quick, accurate and thorough diagnosis and 
of painstaking records of the clinical facts which are obtained. Clini- 
cal methods and clinical records ought to be as systematic and com- 
plete in the dispensary as in the hospital. The facilities afforded by 
a dispensary for the study of physical diagnosis are, if anything, more 
valuable than those of a hospital. The same is true of the opportu- 
nity for learning the methods of diagnosis in minor surgery and the 
application of the ordinary surgical dressings. Practical work in the 
diagnosis and treatment of diseases of women is here feasible and, 
under competent supervision, often proves most valuable. The 
opportunities for studying the specialties of medical practice are also 
of extreme value and should be utilized regularly. Every depart- 
ment of a dispensary ought to be under competent expert medical 
supervision, and all branches should be so conducted as to promote 
the training of students. The practical difficulty in many dispens- 
aries is that the clinical material is not properly utilized. 



p 



104 HL'RU. 

7. Libraries, Reading Rooms, Societies and Journal Clubs. — 
Every hospital should foster a good medical library and a reading 
room filled with the best and latest medical periodicals, and all 
members of the staff should be expected to use them and should 
have time to do so. In most hospitals the medical men are sadly 
overworked, and through a superabundance of routine work lose all 
time, and too often all inclination, for medical reading or study. The 
advantages of a medical society and of a journal club are too obvious 
to require more than a mere brief mention. These organizations 
should exist in the staff of every large hospital. 

a. Medical Staff. — A careful consideration of the subject leads me 
to urge that all large hospitals be furnished with an increased medical 
siaff, and that ihe terms of service of a poriionat least of the medical 
men be considerably increased. It is evident to all wlio have watched 
hospital work that the usual term of service, extending overaperiod 
of \2. 16 or j8 months, brings active young men fresh from medical 
schools into hospitals, to send them out to give place to other inex- 
perienced young men about ihe time they are fitted 10 do independent 
work. The hospital consequently suffers from the mistakes which 
they make while they are receiving training, and by an inexorable 
rule loses their services as soon as lliey are fairly well-trained to do 
efficient and fruitful work. This difficulty would be removed il 
arrangements could be made to give all fourth-year medical students 
routine hospital duties under competent supervision. This would 
train them in practical work toauch an extent that when they assumed 
hospital appointments they would be fitted to undertake independent 
work, and could supervise the work of other fourth-year men wisely. 
In each department of hospital service a chief resident should be 
appointed whose terra ot service should extend over a period of at 
least three years. This would enable him to fit himself thoroughly 
for giving instruction to all assistant resident physicians and to wisely 
direct their work. Such service is possible in European hospitals, 
and if a similar service could be inaugurated in the leading hospitals 
of this country it would mark a decided advance in hospital work. 

inclusion, I would urj^e the duty upon every hospital of doing 
every branch of hospital work as well and as thoroughly as it can 
possibly be done. If philanthropy recognizes it to be a duty to care 
for the sick poor and to minister to their comlort by convenient, 
well-appointed, well- ventilated and well-warmed apartments, the 
duty demands that their medical care shall be equally thor- 




RELATION OF HOSPITALS TO MEDICAL EDUCATION. 10$ 

ough, painstaking and scientific. The best should be constantly 
striven for, and nothing but the best should satisfy those who are 
charged with their care. Every hospital should be an object-lesson 
in the proper care of the sick. It should demonstrate the best 
methods of medicine, surgery and gynecology, the most approved 
nursing, the best cooking for invalids and their kindest care. 

Discussion. 

Mr. Burdett, of London. — I should like to say that I think it is 
very important that we should have a paper of this kind read this 
session. It is important because it clearly lays down and brings out 
clearly to the non-technical mind the reason why the cost of admin- 
istering hospitals tends steadily to increase, and what those who give 
to hospitals really get back in return for their money. A man is 
very often amazed by the demands which are constantly made for 
more and more money, especially for buildings, and I do think that 
Dr. Kurd's paper will fulfil a very useful purpose, and I hope it will 
be printed and widely circulated among hospitals. 

I should like to say further that those who are interested in seeing 
the result of what Dr. Hurd has referred to should certainly go to the 
hospital at the World's Fair. It is situated between the Fine Arts 
Building and the Government •Building of the United States, and 
you will find there objects of the greatest interest to everybody who 
is connected with hospitals. And speaking as a practical man, and 
one who has visited most exhibitions during the past twenty years, 
I venture to say fearlessly that the exhibit in that building is the most 
valuable, as I believe it to be the most interesting, to scientific visitors 
to this city during the Fair. Dr. Billings has had a great deal to do 
with that exhibit, and you will see there illustrated in the most inter- 
esting manner the action of photography, and all the other appliances 
relating to bacteriology and the sciences which now are included in 
the study of medicine. I certainly do hope that many of you will 
go ^ere because I believe it will give you great pleasure. 

I also wish to say in reference to Dr. Cowles' paper that I believe 
the relations of the medical stafT to hospitals must ultimately be 
altered materially. I attribute the great difference in the expendi- 
ture of hospitals largely to the fact that at the present time the 
medical staff gives gratuitous service. I hope to see the day when 
every medical man will be paid for the services he renders to our 



ro6 r,ATHROP. 

hr>spit;i]s, and I believe with the advent of that alteration will come 
the enforcement of true econonjy, and something like a onifonnity of 
Cfpfit in hof^pitaU of the same class. It would confer an immense 
justice on the younger members of the medical profession, and I 
believe if yon will pay the doctors to-morrow that the actual expenses 
of the hospital — and I am speaking as one who has worked for a 
f^reat many years — would tend to be rather less than more than it is 
at present. 



IIOSIMTAI. ACCOUNTS AND METHODS OF BOOK- 
KEEPING. 

By Jamks R. Lathrop, 

Suf>fritiieMdint of the Hoostvilt Hospital^ New York, 

llnvin){ been requested by the Secretary of this Section of the 
Intrrnutional Conjjrcsa to prepare a paper upon " Hospital Accounts 
and Mctluula of Book-keeping," I propose to comply with that 
rr(|iicst by plnciiif; before you, in as brief a manner as consistent 
with an intelligent showing, the methods in that direction which, 
«l\rr yrrtrs of experience, have been found most satisfactory in the 
Roosevelt Hospital, of which I am Superintendent. 

It will be my aim to make mention of those books which may be 
regarded as needful in any well organized hospital, and to illustrate 
the use of them by sketches submitted with this paper. The books 
ntay be enumerated thus : — 

Class A. 

7'itvr tikitk rtlate to Patifnis. 

1st. A book entitlevl ** Admission of Patients/* containing a printed 
form of questions lo Ih^ asked of each patient by the entr>- clerk and 
usuaUy refenxnl t\> as the ** Hislor>' on Admission/' The informa- 
tivM\ oxMnpriscvi in the form is:— • 

PaU 

A<>»v/ «>v^' ."^frV^v^" 

Hrt'ij \C<" ,«,»,««/>«'*Tt^<j<*^ ,.,..•. ...... 

,'\i »¥^.M.c** /7V*A" .V'^^^* in l\ S .^^y i^m^ r« Cxtr 



HOSPITAL ACCOUNTS AND METHODS OF BOOK-KEEPING. IO7 

How admitted 

Apparent ailment when admitted 

Name and Address of Friends 

Had Patient Valuables Left in office 

Examined by Dr, 

Discharged 

Diagnosis at Discharge 



2d. A register entitled ** Admissions and Discharges," not alpha- 
betically but chronologically arranged, and designed for recording 
daily changes in detail, each admission and each discharge in numer- 
ical order from the date of the opening of the hospital ; for example, 
the first patient received into the Roosevelt hospital on the occasion 
of its opening, Nov. 2, 1871, was numbered 1. The first patient dis- 
charged was also numbered 1, although the two were not identical. 
In other words, the number 1 did not necessarily mean the same 
patient. On the first of this month the admissions had reached a 
total of 40,368, while 40,222 represented the number discharged. 
Subtracting the one from the other showed the admissions to have 
been 146 more than the discharges. That difference represented the 
number actually remaining in the hospital on June ist. 

3d. A book entitled "RegisterofPatients," alphabetically arranged, 
and written up daily from slips of admission and bedside cards which 
accompany patients to the wards when admitted and are returned to 
the office upon their discharge. The cards contain the following 
items of information : — 

Wardy (to which patient belongs) 

Division, (with which connected — Medical, Surgical, or Gyneco- 
logical) 

Name of Patient 

Age Birthplace 

Civil condition, (married or single) 

Parentage Occupation 

Years in [/. S Years in City 

The cards are signed by the entry clerk in the name of the Super- 
intendent when patients are sent to the wards, and when discharged 
are signed by the House Physician, Surgeon, or Gynecologist, who 
then records thereon the diagnosis and information as to whether 
the patient had been discharged " Cured," " Improved," " Not 



I08 . LATHROP. 

Improved " or " Dead," These cards furnish the means for " closing 
the accounts " of patients on the " Register of Patients.*' This book 
is designed, primarily, for use in readily ascertaining the presence of 
patients in the hospital at time of inquiry or at a prior date. 

4th. A book entitled " Record of Rejected Patients," whose appli- 
cation for admission has, for any reason, been refused. The infor- 
mation therein recorded is : — 

Date of Application 

No (in order of application each month — thus showing how 

many persons have been refused admission during the month). 

Name and Residence, (of applicant) 

By whom recommended 

Date of examination 

Where examined^ (whether at the hospital or elsewhere) 

By whom examined, (what physician or surgeon) 

Diagnosis 

Disposition of case, (that is, why rejected; whether because of lack 
of room or for the reason that the applicant's malady did not 
come within the scope of the work of the hospital, and where 
referred.) 

5th. A book entided " Daily Record/' containing a census of 
patients in the hospital. This is written up in the entry clerk's 
office — the information being gained from returns made by the nurse 
or orderly in charge of each ward. If the returns do not agree with 
the number shown to be in the hospital by deducting from the 
number representing the last admission that number representing the 
last discharge (as illustrated in my reference to the book entitled 
" Admissions and Discharges,") an investigation is instituted to 
account for the difference. 

6th. A book entitled " Statistics for the Annual Report." This is 
a record showing the nationality and sex of the discharged patients. 
It is written up at least once a month. The course of procedure is 
very simple. There are forty lines on each page of the book of dis- 
charges ; each line represents a case ; first ascertain the number of 
males and then of females ; the sum of both must be forty ; then 
learn the number of males of each nationality represented and again 
the number of females; the sum of all the nationalities of both sexes 
must be forty. The results are tabulated in this book (*' Statistics 
for the Annual Report") and at the end of the year are footed up, 



HOSPITAL ACCOUNTS AND METHODS OF BOOK-KEEPING. IO9 

this quickly giving the desired information. In a hospital where the 
changes are numerous such a book is very helpful. 

7th. A book entitled ** Receipt Book for Effects," belonging to 
deceased patients and designed to show, by the signature of receiver, 
to whom delivered. This book is kept by the entry clerk. In another 
book a record is kept of valuables deposited by patients on 
admission. 

Class B. 
Those which relate to Officers and Employees^ 

ist. A book entitled ** List of Officers and Employees," an alpha- 
betical register in which the signatures of the employed are taken 
(at the time of their engagement) to a printed contract at the head 
of each page, reading : 

"Contract: I, the undersigned, accept the terms herein mentioned, 
agree to do faithfully the work assigned to me, and to conform to all 
rules of the Hospital while in its employment ; and it is distinctly 
understood and agreed, that whether I am paid by the day, week, 
month or year, my engagement is to terminate upon notice by the 
Superintendent that my services are no longer required ; and, upon 
payment being made to me for the actual time of service rendered, I 
agree to accept and receipt for the same in full consideration for all 
demands against said institution. The Hospital reserves the right to 
deduct for absence from whatever cause." 

In this book, in addition to the signatures of the employed, appear 
the following items of information: — 

Name, (written by the clerk) 

Employment, (to which assigned) 

By whom recommended,,, 

Date of employment 

Salary or Wages 

Lefty (date) and cause (to be recorded by the Superintendent). 

The value of this book consists not only in having the signature of 
the employed to a very definite contract, but in preserving such 
information with respect to the nature of the employment, time of 
service and cause of leaving as to enable a superintendent to return 
an intelligent answer to any inquiry made concerning a former 
employee, or to refresh his own memory in the event of an applica- 
tion for re-employment. 



I lO LATHROP. 

2d. A " Pay Roll '* of officers and employees, classified by depart- 
ments — employees in each department being grouped together, and 
the signature of each being taken when receiving pay for services 
rendered. At the top of each page is a printed heading reading: 
•* We, whose signatures are hereunto subscribed, severally acknowl- 
edge to have received the sum set opposite our respective names, 
being wages in full for the time specified." Opposite each name are 
two columns, of which one is used to record the number of the 
employee in the particular department in which he is engaged, and 
the other to indicate the total number of employees in the hospital. 
This information is utilized at the end of every year in determining 
the daily average number of employees throughout the year. In 
this class of books I may refer to one entitled " Record of Attend- 
ance of Visiting Staff." It is designed to show the hour of arrival 
and departure of the physician or surgeon on duty in each division 
of the hospital during the successive days of the year. One line is 
devoted to each day. If any one of the three divisions of the hos- 
pital is not visited by a member of the visiting staff, the fact becomes 
apparent to the visiting member of the board of trustees, who may 
invite an explanation. 

Class C. 

Those which relate to the Purchase of Supplies. 

1st. The *' Order Book," in which are recorded, in duplicate, all 
orders given for supplies — one, the stub, being retained for future 
reference, and the other delivered, over the signature of the Superin- 
tendent, to the dealer, who, by a foot-note, is enjoined to supply a 
bill with every article furnished, and to furnish no article except upon 
the order of the Superintendent. 

2d. A book entitled "Account of Supplies and Materials Received," 
in which are recorded all invoices of goods received, their receipt 
having first been certified to by the head of the department for which 
the goods are intended. The headings in this book are: — 

Remarks 

Articles, with quantity and cost, 

From whom purchased 

Dealers^ Ledger folio (indicating the page therein on which 

the date and amount of an invoice may be found). 



HOSPITAL ACCOUNTS AND METHODS OF BOOK-KEEPING. Ill 

3d. A book entitled "The Dealers' Ledger," posted from the 
register just described, and in which are written the names of the 
dealers and the amounts of their invoices. 

These records render it possible to file the invoices when audited, 
paid and receipted, the " Dealers' Ledger " and *' Account of Supplies 
and Materials Received " being available for reference whenever it 
becomes desirable to learn the source of supplies and the prices paid 
for them. They are only books of memorandum and should not be 
confounded with the General Ledger of the hospital. 

4th. A book in which are recorded the minutes of the weekly visiting 
committee of the board of trustees ; an important duty of that com- 
mittee being to audit the dealers' bills and monthly pay-roll, pre- 
sented by the Superintendent for approval before payment. They 
also inspect the weekly reports of patients admitted and discharged, 
and attend to such other matters as are brought to their notice. 

5th. A book containing drafts upon the treasurer for the sum of 
the audited bills, and signed by the weekly visiting committee 
referred to. 

Class D. 
Those which relate to the receipt and payment of moneys, 

ist. A book of blank forms of " Receipts," with stub, used for 
acknowledging the receipt of money paid for the board of patients. 

2d. A Petty Cash Book, in which an entry is made of all moneys 
received and paid out at the hospital. 

3d. A Cash Book, in which weekly entry is made, in a classified 
form, of the receipts and expenditures recorded daily in the Petty 
Cash Book. 

4th. A Patients' Ledger, which is really part of the General 
Ledger, but, for convenience, is bound under separate cover. In it 
credit entries are made from the Cash Book to the individual accounts 
of patients, of such sums of money as are received from them for 
board. In this book debit entries are also made from the Cash Book, 
for any sums that have been refunded because of their discharge 
before the expiration of the time for which board has been paid. 
The accounts in this book are balanced by entries, from the Journal, 
of charges there made for board during the actual time of stay in the 
hospital. 

5th. The "Journal." This is the book of original entry for : — 

1st. Recording all hospital expenses paid by the treasurer. 



112 LATHROP. 

2d. Recording the weekly total of petty expenditures, appearing 
in detail in the Cash Book. The money is drawn for the same from 
the treasurer in gross sums by draft of the visiting committee. 

3d. Charging the individual accounts of paying patients with 
board, etc. 

4th. Charging ** Board Account/' by a single entry, with the total 
amount received from paying patients during each week, and credit- 
ing " Paying Patients' Account" with the same, the details appearing 
in the Cash Book. 

5th. Charging Paying Patients' Account monthly, by a single entry, 
with the total amount refunded to paying patients discharged before 
the expiration of the period for which they had paid board in 
advance, and crediting " Board Account " with the same, the details 
appearing upon the Cash Book. 

6th. The " Ledger." This book contains all general accounts 
other than dealers' and those of individual paying patients. 

7th. A book entitled the " Expense Book." The trustees of the 
Roosevelt Hospital regard this as one of the most valuable books of 
its kind for their use kept at the institution, for the reason that it 
affords an opportunity for an analytical comparison of the expenses of 
the hospital, monthly as well as annually, the expenditures under 
each head being so classified as to facilitate ready comparison. It 
has therefore seemed to me best to illustrate its use by making my 
sketch of this book a complete transcript from the record of the 
original for the past year. 

In presenting these sketches with the accompanying explanations, 
I wish to say that superiority over methods employed by other insti- 
tutions is not claimed for them. They are representative of the 
system followed at the Roosevelt Hospital, and are the outgrowth of 
my own experience there and elsewhere. My one motive in accept- 
ing the invitation to treat this subject was a desire to be helpful to 
new institutions confronted with the necessity of adopting a plan of 
bookkeeping which would be adequate to their needs. This must 
be my excuse for the minuteness of detail which you may have 
remarked. The most I could hope for, in the case of the older insti- 
tutions, was that some modification of their present system might 
be suggested by a consideration of the varied list presented. 



Forms on 

pages 
115-X18. 



HOSPITAL ACCOUNTS AND METHODS OF BOOK-KEEPING. II 3 

The following memoranda and specimen pages are appended to 
give those who desire them definite details for guidance in ordering 
similar books or forms. 

Class A, No. I. See page 106. Binding, cloth sides, leather 
back and comers. Size, 250 leaves or 500 pages, each loixyi inches. 
2 blanks to each page. 

No. 2. Admissions and Discharges. See page 107. 

No. 3. Register of Patients. See page 107. 

No. 4. Record of Rejected Patients. See page 108. 

No. 5. Daily Record. See page 108. 

No. 6. Statistics for Annual Report. See page loS. 

No. 7. Receipt Book for Effects. See page 109. Binding, three- 
quarter board, marble-paper sides, roan back and ends. Size, 200 
leaves ; printed one side ; one form of receipt, each 3lx8 inches. 

Class B, No. i. List of Officers and Employees. See page 109. 
Binding, full sheep. Size, 150 leaves or 300 pages, i2ixioi. 
Indexed throughout, or from front to back. 

No. 2. Pay Roll. See page 1 10. Binding, full cloth with duck 
cover. Size, 100 leaves or 200 pages, each I4ixi2i. 

No. 3. Record of Attendance of Medical Staff. See page 1 10. 

Class C, No. i. Order Book. See page no. Binding, cloth 
sides, leather back and corners. Size, 200 leaves, printed on one 
side, two blanks to each page, with duplicates as stubs for retained 
copies of orders; each page i2xioi inches. 

No. 2. Account of Supplies and Materials Received. See page 
no. Binding, cloth sides, leather back and corners. Siz^, 250 
leaves or 500 pages, i2ixioi inches. 

No. 3. The Dealers' Ledger. See page in. Binding, extra 
full sheep. Size, 250 leaves or 500 pages, i2ixiof inches. 

No. 4. Minutes of Visiting Committee. See page in. Binding, 
full sheep, with duck cover. Size, 200 leaves or 400 pages, iiixQ 
inches. 

No. 5. Draft Book. See page in. Binding, cloth sides, leather 
back and corners. Size, 200 leaves, printed one side, 5 drafts to 
each page, i6ixi3i inches. Drafts perforated, and drafts and stubs 
numbered in duplicate from i to 1000. 

Class D, No. i. Receipts. See page in. Binding, full duck. 
Size, 150 leaves or 300 pages, each 12x9} inches, four blank receipts 
to a leaf, with endorsement on back of each as follows : " Payment 
for board and treatment must be made for four weeks in advance. 



114 LATHROP. 

The amount of two weeks' board at the rate agreed upon will be 
retained in every case, though the patient remain a less time in the 
Hospital." 

No. 2. Petty Cash Book. See page iii. Binding, full red 
leather. Size, 150 leaves or 300 pages, each 9lx6i inches. 

No. 3. Cash Book. See page iii. Binding, extra sheep, with 
duck cover. Size, 250 leaves or 500 pages, each isJxioi inches. 

No. 4. Paying Patients' Ledger. See page m. Binding, extra 
sheep, duck cover. Size, 250 leaves or 500 pages, each islxioj 
inches, ruled for four accounts on each page. 

No. 5. Journal. See page iii. Binding, extra sheep, duck 
cover. Size, 250 leaves or 500 pages, each 15IX10} inches. 

No. 6. Ledger. See page 112. Binding, extra sheep with duck 
cover. Size, 250 leaves or 500 pages, each 15JX10}, ruled for one 
account to each page. 

No. 7. Expense Book. See page H2. 

















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I20 LATHROP. 



Discussion. 



Mr. Burdett, of London : I shall have to speak on this subject 
to-morrow, therefore I will not say much about it in the Section, but I 
should like to say this. As far as I am able to follow the paper, 
which is necessarily very technical and very difficult to follow, I do 
not see any account of a subscription register among the numerous 
books which Mr. Lathrop gave us at some length. Now there is a 
good deal of attention paid to another book, and that is the ledger 
for paying patients, and I only rise here now on this point to say how 
grateful and thankful I am to the United States that they, in a new 
country,* and having to build new institutions, founded the hospitals 
on the principle that every man shall have held sacred to him the 
right of contributing anything which he can afford to his maintenance 
in the institution. There is nothing doing more injury to the old 
countries of the world than the continuous, ever-increasing amount 
of free medical relief which is being given in our medical institutions. 
I am confident that the out-patient department is the portal to paup- 
erism. It is there that people begin to learn that they can get 
something for nothing, and they are not ashamed of doing it. From 
there they pass into the in-patient department, where they get great 
benefits and large expenditures upon them, without any effort on 
their part, without being required to defray any part of the cost of 
the treatment and maintenance. Finally, if they should be in a 
surgical ward or have an appliance of any kind, they are positively 
given that apparatus without any attempt on their part to give one 
penny of the cost. Now the evils attending free medical relief are, as 
I said before, most momentous, they are disastrous and destructive of 
all the principles of independence ; and whereas I would be the first 
to advocate the fullest and fairest and largest amount of help to men 
or women who are unable to provide it for themselves, I do, as I said 
before, thank the United States that in this country at any rate, 
to-day, the first thing an applicant for medical relief is made 
acquainted with is the fact that he is entitled to the privilege of pay- 
ing what he can toward the cost of that relief. 

There is one word of warning I would like to utter. I was in New 
York last week and I visited some of the hospitals there, and I found 
at least in one of them the truth of the statement made by Professor 
Peabody yesterday, that where there are philanthropists and where 
there is a vast amount of money to be distributed, there comes the 



HOSPITAL ACCOUNTS AND METHODS OF BOOK-KEEPING. 121 

danger to the individual citizen, because the amount of funds in one 
of those hospitals is so large that I am told (and I verified it by the 
figures) that the tendency there is to increase the free beds and to 
decrease the paying beds. Now that increase is being made without 
proper and adequate and full inquiry, so far as my investigations 
went ; and I do certainly hope that the administrators of the great 
American hospitals will set their faces like a rock against the devel- 
opment of free beds, until they are perfectly certain that in any large 
population where this subject comes up for discussion those free beds 
are absolutely necessary to provide for those who cannot in any way 
or to any extent provide for themselves ; otherwise we shall see that 
our anchor, the anchor of hope of the United States, is gradually 
slipping. And what will become of us in the Old World I don't know, 
except we arrive at this stage, that everybody will get free medical 
relief; because it has grown from 1870, when we had one in three, till 
1880, when we had one in two of the whole population who got free 
medical relief; and according to the last figures, one in every one and 
a half of the population now receives this free medical relief. I do 
therefore hope that looking at this question in its widest bearings, 
from a single point of view, you will be proud of this system ; that 
you will let nothing interfere with it, or tend to break it down, and 
that your basis shall be : ** Show us that you require free medical 
relief and you shall have it ; but you must prove the necessity before 
we offer, nay, before we will ever attempt to thrust upon you this free 
gift, which, though a gift, may tend to weaken your moral fiber and 
thereby lessen your uses and privileges as a citizen." 

Mr. C. C. Savage, of New York : This question which Mr. 
Burdett has raised in regard to free beds is one of the most vital 
questions affecting the whole hospital discipline. As far as New 
York is concerned, our private hospitals are supposed to be pay 
hospitals, but ninety percent, are really free. Any one who looks at 
the subject knows that that ought not to be so. I fully agree with Mr. 
Burdett on that point. But how to effect a remedy is a matter which 
has not yet been solved. And what income should a patient have 
in health to entitle him to a free bed ? Some sum might be adopted 
as a guide ; shall it be an income of ten dollars a week or fifteen 
dollars a week ? Then again comes up the question, whether he 
has a wife and children dependent on him or not. All these ques- 
tions come up, and we find it almost impracticable, if not quite so, to 
lay down any rule which shall govern the free beds. The tendency 



122 LATHROP. 

is With US, Mr. Burdett, as it is with you, to increase rather than to 
diminish free beds. If some method could be devised by which 
more pay patients should be received in our hospitals, or more money 
received from those who are now free patients, we should undoubt- 
edly uphold the moral stamina of the patient, and relieve the hos- 
pital of the great burden of their support. 

Mr. Burdett: I should like to say that I don't think, from our 
experience, you can work the weekly wage at all ; but I do think 
this : if you give a patient the privilege of paying, and force home 
your principle, which is the kernel of the whole question, that a man is 
expected to pay, at any rate a minimum sum, you fix a minimum 
charge and you will usually get it. The cottage hospitals, of which 
there are now six hundred in England, have grown up in the rural 
districts, where the population have lower wages than anywhere 
else ; there the patients pay half a dollar a week at least, most pay a 
dollar and a quarter, and we find in that way the people are always 
cheerfully willing to pay this ; very many pay much more. The 
best way is not to strike a wage limit, but to deal with each case ; 
and that can be done by the superintendent or the board of visitors, 
who examine these cases, and say : " Well, you must prove to us that 
you require free relief, or you won't get it ; you must at any rate pay 
the minimum charge." 

The Chairman: There is no hospital which publishes statistics of 
its patients and its results in such a way as to be comparable with 
other hospitals, for the reason that no hospital gives the figures in 
groups of ages. In making up a life table, or in collating vital 
statistics, we want to know the number of persons of each of certain 
age groups, as from 20 to 25 years, that have been in a hospital for 
a given lime ; then the number of deaths that take place out of that 
number. Now some hospitals give us the number of deathg by years 
of age, but they do not give us the age groupings of the patients 
who do not die, and hence the data for calculation of ratios are 
wanting. In my judgment, a record of a hospital should be summed 
up once a month, the number of patients, with distinction of sex, and 
the number of patients in each group of years. It is impossible to 
compare statistics of mortality of different hospitals, or of different 
methods of treatment, unless you know the ages of the patients 
treated. One of the best things that could be done for scientific 
medicine and vital statistics in this country would be, in all our old 
hospitals and asylums for the insane, to go over the old records and 



HOSPITAL ACCOUNTS AND METHODS OF BOOK-KEEPING. 1 23 

take out the data of all patients by quinquennial age periods, and the 
deaths in the same way, and so get them into a shape in which they 
would be comparable. 

Lt.-Col. J. Lane Notter, of England : I should like to add to your 
remarks, Mr. Chairman, how very important this question of statis- 
tics is in England. We found that comparison was almost impossible 
until we attempted this method of age grouping. Take for instance 
consumption : in what ages does this disease occur ? Now this is 
most important with reference to factory legislation. In factories, 
where large numbers of young people are exposed to humidity and 
the atmospheric conditions which are found in workshops, it is espe- 
cially liable to develop. By getting these groups of ages we can 
tell the average lifetime that these people are likely to last, and we 
can take such preventive measures as have been taken lately in Eng- 
land in order to minimize the evil attending working in such factories. 
Age grouping of hospital statistics has a much larger bearing than at 
first appears upon sight, because it gives an insight into the causes 
of mortality ; it aids us in taking these preventive measures which 
reduce the causes of disease, and enables. the statistician to point out 
what is the saving in life and the probable mitigation of the number 
of deaths which occur in the early period of life and among people 
engaged in unhealthy trades of all kinds. 

In military life we have also found it of the greatest advantage ; 
not only is the age group given, but the actual numbers furnishing 
the sick are given. We can tell easily enough whether the younger 
men or the older men living in a tropical country, under the skme 
conditions, suffer most It really is an important point, and well 
worth the attention of those who have the charge of hospital accounts 
and books. 

Dr. Kurd : I asked Mr. Lathrop to prepare this paper because 
I was extremely anxious that all hospital workers throughout the 
country should see the forms in use at Roosevelt Hospital, where 
I think the system of business methods is exceptionally good. I 
think in this country, especially in smaller hospitals, a great and 
increasing difficulty has always been the lack of business methods. 
I learned of a hospital the other day in a city of 250,000 to 300,000 
inhabitants, where a new superintendent had gone into office and 
found a fine hospital disorganized in every department. The matron 
bought what she felt like buying, and the engineer and superinten- 
dent of nurses bought likewise. Each one of the resident physicians 



ordered drugs and supplies by telephone, without any regard to 
what might have been ordered by any one else; and the result was 
that a score of people in that institution were buying supplies with- 
out autlioriiy, without system, by telephone, and by word of mouth, 
until the expenses of the hospital were such as to frighten the con- 
tributors. The situation required a very determined stand on the 
part of the superintendent, who had the satisfaction of cutting down 
the expenses of the hospital very materially, by introducing a syste- 
matic method of purchase and a strict responsibility for all payments. 
He informed me he found it necessary to take stringent measures to 
make the change, and in several instances to require those who 
ordered goods to pay for them. One officer, in fact, felt so much 
aggrieved by the limitation of his prerogative that he resigned; he 
could not endure to be in an institution where he could not buy what 
he pleased. For these reasons I am extremely anxious that these 
forms should be followed In smaller hospitals, in order to insure the 
economical expenditure of hospital money. 

Mr. C. C. Savage : If there are any superintendents or trustees 
of hospitals present, I would call their attention especially to the 
Expense Account Book, I know an Expense Account Book is of 
great value in comparing what has been purchased and its cost from 
time to time. It has to me a wonderful value in [hat line. I think 
every trustee would find it so by experience. 



ON PAYING PATIENTS IN HOSPITALS. 
By Henry M. Lyman, A. M., M. D., 

f of tilt Altcndins Physiciam to The PreibyltriaH Hospital in Chicago. lilt. 

As an example of the experiment of requiring payment for hos- 
pital service, I desire to relate the experience of The Presbyterian 
Hospital in Chicago. This hospital was erected under the auspices 
of the Presbyterian churches in this city, at a cost of about one 
quarter of a million dollars. It furnishes accommodation for two 
hundred and twenty-five patients. Its staff of officials and employees 
resident in the building consists of a Superintendent, who is a physi- 
cian, six interne physicians and surgeons, forty-three nurses furnished 



ON PAYING PATIENTS IN HOSPITALS. 1 25 

by the Illinois Training School for Nurses, and seventy-three subor- 
dinate servants, making a total of one hundred and twenty-three 
persons actively engaged in the hospital. The nurses, however, do 
not sleep in the building. At night the day nurses retire to their 
rooms at the Illinois Training School, a short distance from the hos- 
pital, and their places are occupied by the night nurses, who, in their 
turn, leave the building in the morning. The medical and surgical 
service of the hospital is in the hands of a visiting staff of physicians 
and surgeons who reside in the city. Any patient who desires such 
an arrangement can employ any reputable physician or surgeon to 
attend him in the hospital, even though not connected with the hos- 
pital staff. This privilege has thus far worked without friction ; and 
it is often a great convenience for an outside physician or surgeon to 
avail himself of the advantages of hospital nursing and attendance 
while caring for a patient who otherwise would have been relegated 
to the imperfect installation of a private house or a hotel. 

At the outset of their undertaking the directors of The Presbyte- 
rian Hospital resolved that so far as possible they would seek to 
avoid everything that tends to pauperize the community. It is 
believed that the great County Hospital affords sufficient accommo- 
dation for the really indigent poor of the city and county. It is, 
therefore, understood that patients who seek admission to the Pres- 
byterian Hospital must pay for the services there rendered. If 
unable to pay, they must have payment made for them by some one 
else. Medical and surgical attendance must also be paid for, just as 
if the patient were in his own house or in a hotel. As a matter of 
fact, however, the members of the medical staff are exceedingly 
lenient in this matter and have never exacted payment from any 
patients who were in straitened circumstances. In this arrange- 
ment the members of the medical staff deal with the patients very 
much as they would treat similar individuals in their clientele outside 
of the hospital. Thus far the experiment has proved very successful 
and satisfactory. 

Returning now to the subject of hospital finance alone, it appears 
that during the year that ended March 31, 1893, the daily average 
number of patients under treatment was one hundred and eighty. 
The total annual expense of the hospital during that period was 
$83,447.15. The daily cost per patient was $1.27, making the weekly 
cost per patient $8.89. This sum, therefore, represents the unit of 
hospital charges. But since many patients require much more than 



1 26 LYMAN. 

the bare necessaries of hospital accommodation, the charges are 
graduated in such a way as to afford different degrees of accommo- 
dation and outlay. The weekly charge is, accordingly, graduated 
from three dollars to twenty dollars per week. During the year 
ending March 31, 1893, ^^^ weekly charges were as follows : Free to 
843 patients ; $3 to 27 patients ; $5 to 77 patients ; $6 to 154 patients ; 
$7 to 87 patients ; $8 to 527 patients ; $10 to 249 patients ; $12 to 136 
patients ; $15 to 160 patients; $20 to 39 patients. 

The amount of money received from these patients reached the 
sum of $58,751.54, leaving a deficit of $24,695.61. Of this, $19,500 
are made up to the hospital by the income from endowments furnished 
by charitable individuals and by different churches that contribute 
yearly gifts for the maintenance of free beds. These contributors 
are permitted to designate patients who shall be the recipients of their 
charity, and in this way many of the city churches provide hospital 
care for their indigent members. In this way provision is made for 
sixty-five free beds each year, and the income from this source, 
amounting to $19,500 during the year ending March 31, 1893, sodded 
to the income from patients who paid their own way, makes a total 
of $78,251.54, leaving an actual deficit of only $5195.61. This sum 
is finally liquidated by the benevolent contributions of the different 
Presbyterian churches in Chicago. 

By the method thus outlined, it is evident that the hospital is 
actually on an almost self-supporting basis. Were it not for the 
large number of patients in the so-called " free beds," from which the 
income is less than the actual cost of maintenance, the hospital could 
easily be made self-supporting, so great is the number of patients 
who would gladly pay full price for the privilege of admission. It is 
true that the cost of the original installment, its enlargement, and extra- 
ordinary repairs, is left out of view in these estimates, consequently 
the fact remains that the Presbyterian Hospital of Chicago, with all its 
high endeavor to avoid the semblance of pauperizing its constitu- 
ency, is none the less a monument of charitable purpose and action. 
No patient enters its doors unless he pays or has payment made for 
him, according to the services rendered ; yet no one does make and 
very few can make any adequate pecuniary return for the use of the 
immense investment of capital and good-will that is represented by 
this noble charity. 



on paying patients in hospitals. 12/ 

Discussion. 

Mr. Savage, of New York. — You have an expense for repairs, I 
suppose ? How do you meet that ? 

Dr. Lyman. — The expense is met out of this income ; that is in- 
cluded in the general expense, all these things are included in the 
general outgo of eighty-three thousand (dollars. The building is not 
included in that ; a new building when needed will have to be pro- 
vided for by gift. 

A Delegate. — Are there not individual endowments as well as 
the endowments of the churches ? 

Dr. Lyman. — There are some; I should have said there have 
been some. 

Mr. Ryerson, of Chicago. — I am very glad to hear Dr. Lyman's 
speech, because it is a subject I have always taken a great interest 
in and given a great deal of thought to. The institution I have 
the honor to preside over is an old institution, that is, old for 
this city, probably the oldest charity in this city, and we have 
been met there, in this question of pay patients, with the feeling, 
that I think is gradually becoming more common, that a hos- 
pital was not necessarily an institution of charity. Now I think 
there is a great deal of truth in what Dr. Lyman has said, that you 
may do a man just as much harm by pauperizing him when he 
is ill as by doing it when he is well ; and in sort of an intuitive way 
I have come around to see it myself. I think I began in my past 
experience with the idea that a hospital is necessarily a charitable 
free institution, and an institution like St. Luke's Hospital, which I 
represent, which has grown up gradually, and was not begun in the 
scientific way that the Presbyterian Hospital was, has difficulty in 
meeting this question, and I should like if possible to have some 
light thrown on these difficulties now. At the time St. Luke's was 
begun, the County Hospital, with its splendid provision for charitable 
work, was not in existence, and therefore the public looked to insti- 
tutions like St Luke's for help. Consequently, when I first became 
identified with the hospital I found a feeling very largely prevailing 
among the friends supporting the hospital, that we were in some way 
violating our pledge to the public by taking pay patients, and it has 
been a great difficulty with me. I hope in some way this paper of 
Dr. Lyman's will be made public, because I think that the public 
ought to know that just as much good is sometimes done by an 



128 LYMAN. 

institution which does not attempt to pauperize a man because he 
is ill, but regulates its charges by his condition ; that is the true sci- 
entific plan, I think. All I have ever done is to tell my superinten- 
dent to exercise his tact and his discretion in the matter, to get at the 
facts as best he may, and then regulate the charges according to the 
patient's circumstances. Of course we base our regular charges, as 
the Presbyterian Hospital does, upon the per diem cost. 

Then another question. We have a large number of endowed 
beds, some by money left us and some by money given us, and I 
think as a rule we are able to take as many free patients as these 
endowments provide for; but circumstances might arise when we 
would not be able to take as many free patients. If our income fell 
off in any other direction we could not receive such patients. 

Then in what position do hospitals who have received endowments 
stand to those persons who have furnished such endowments ? I 
have known of cases where people who have subscribed some sum 
to the institution, take advantage of that position to send down to 
us their servants or dependents, and expect us to give them free 
medical service and care, and all at the expense of some imaginary 
account. Now that is a very embarrassing situation, and it is a 
situation that a hospital that is bound by these endowments is tied 
up by. It seems to me that you cannot attempt any fairer plan than 
this: I figure out my final income, and then earn enough money 
from my pay patients to come out square at the end of the year. 
That has been the plan that I have endeavored to go by. 

Dr. Pilcher, of Brooklyn. — I was hoping, as Dr. Lyman pro- 
gressed with his account of their arrangements, inasmuch a I under- 
stood him to say that he is one of the attending physicians of the 
hospital, that he might give us some information as to the arrange- 
ments which are made by the paying patients of the hospital as to 
the remuneration paid to the attending staff; for I take it that just at 
this point there is an extremely important question involved in hos- 
pital management. It always has been the part of members of the 
medical profession to devote themselves personally to the care of 
unfortunates who are dependent upon charitable relief, as a part of 
their contribution to the great fund of charity. We are always 
ready to devote ourselves personally to the care of those people who 
are proper candidates for charitable relief, but as I understand it, in 
this institution there are at least two-thirds of the patients who are 
not proper candidates for charitable relief. I would like very much 



ON PAYING PATIENTS IN HOSPITALS. I29 

to know whether in this institution it is required of members of the 
staff who attend the charitable patients without pay, to also attend 
without pay the pay patients ? 

Dr. Lyman. — I will say with regard to that matter that the patients 
in the hospital can be classified into two classes, the productive 
patients and the unproductive ; all those who pay or have paid for 
them a sum per week not exceeding eight dollars are considered 
unproductive patients, and they are attended, so far as medical and 
surgical attendance is concerned, gratuitously by the staff of the hos- 
pital. The productive patients are those who pay ten dollars or 
more per week ; they are allowed to make such selection as they 
please. as to attendance. We have a somewhat peculiar method of 
attendance in the Presbyterian Hospital that has so far worked very 
well indeed. 

Persons who come to the hospital who come under the head of 
productive patients and are promised extra privileges in the way of 
room and attendance have also the privilege of selecting their medical 
and surgical attendant, and they are attended by the regular hos- 
pital staff or by any resident physician in the city or out whom they 
choose. With the matter of medical compensation the hospital 
management has nothing to do ; it only knows that its patients who 
are unproductive will be attended by the hospital staff gratuitously, 
and that those who are productive will pay their own physicians and 
surgeons, just exactly as they pay their physicians and surgeons in 
their own home. 

Dr. Pilcher inquired whether any steps were taken to ascertain 
whether those who desired accommodation at eight dollars per week 
were able to pay more. 

Dr. Lyman stated that it was understood a man did not go into 
the common wards unless he was obliged to. 

Dr. Pilcher. — That hardly answers the question. Human nature 
is perhaps the same all the world over, and there are doubtless men 
who are perfectly satisfied with the accommodations of the general 
ward who would be able to pay considerably more than that. The 
question is, are the common wards restricted to those who are not 
able to pay more than eight dollars a week ? 

Dr. Lyman. — No, I do not think there is any examination made 
as to the ability of the patient to pay more; the schedule of prices 
is presented to him and he selects. 

Dr. Pilcher. — It is quite apparent that an opportunity is here 



I30 



medical attention who wouTa 



presented for people to obtain gratui 

be perfectly able to pay the proper fees. 

Mr. Burdett. — I should like to say that it is a great pleasure to 
me to meet a representative of the Presbyterian Hospital of Chicago. 
1 have been trying for years to ascertain how that institution is con- 
ducted, and I had come to the conclusion that possibly the books 
were somewhat complicated, or there was some other reason why we 
could not get some information. St. Luke's Hospital has always, 
and even the Cook County Hospital has sent us tables for the pur- 
pose of comparison, and — as I shall have to point out to-morrow — 
the work which we endeavor to do is done in the interest of all the 
hospitals, not in the interest of any individual person at all. It is a 
very considerable labor and considerable expense, and I do hope 
that one result of this congress will be that instead of having one 
hospital only of which we have any knowledge in Europe (because 
thai is the only institution that will supply even a report), that in 
future years we shall be able to give a proper account of every hos- 
pital in Chicago. I only mention that by the way, I hope I may 
say it without any offense at ail ; I am quite sure from the answers 
given by the reader of the paper and the evident interest he takes in 
hospitals that it will be his desire, as it is mine, that full justice shall 
be done to every institution in Chicago by the authorities who are 
responsible for supplying details. 

Now in regard to the point at issue. The president of St. Luke's 
has said that he has endeavored to build up a system of paying 
patients. If you go through St. Luke's and examine the books, as I 
did, you will find that ihe receipts from paying patients have gone 
up and the receipts from churches have steadily gone down. Now 
I venture to say (I speak quite freely and frankly) that this is a fact 
which the people of Chicago should take very closely to heart. It is 
a condition which is not worthy of the intelligence of a great city, 
because I have gone most carefully into the system presented at St. 
Luke's Hospital, and I find that every poor man is taken in freely, 
and that every other man is allowed to come in and pay what he can. 
This is the system in vogue at St. Luke's ; 1 have personally verified 
it; and I spent some two hours in going into it yesterday, and I 
declare it is one of the best systems that a hospital can be conducted 
on, and I believe it is the only safe system and satisfactory way ia 
which you can conduct a hospital. Now if this is so, what can we 
say to the churches of this city who positively every year, as this 




ON PAYING PATIENTS IN HOSPITALS. I3I 

system is being improved, show less and less interest ! It is a fearful, 
a most troublesome thing, and I do really hope that the newspapers of 
Chicago, which I find very interesting reading, from their lightness, 
will have a serious turn to-morrow morning, and that at any rate one 
editor in the city will find, say six lines which he can spare to this 
question in the leading column, considering its interest, its import- 
ance and its worth. I am afraid there is no reporter present ; but I 
know by past experience in Chicago that even walls have ears ; 
there is an editorial ear in some wall here and I hope it will take this 
seriously to heart. I notice they take great credit for exposing 
rogues ; let them take credit for one day for exposing the fact that 
St. Luke's Hospital, situated in one of the poorest districts of the 
city, is doing a glorious work in the best possible way and the 
people of Chicago are every year turning their backs more and more 
upon it ! Shame ! Let this not be continued 1 

Now, sir, with reference to what you said with reference to the 
question of the medical staff; I am one of those who have come to 
this conclusion, that for the well-being of all the hospitals I would 
pay every medical man who gave any services whatever to any 
hospital, because I believe that the payment of the medical staff will 
represent a less sum than the eleemosynary system of relief which 
the great medical profession have given for so many years free. 

I would say also that while I know nothing about the case of the 
Presbyterian Hospital, individually, I think it is quite possible that 
Dr. Lyman, in his desire to be fair and to state nothing beyond his 
own knowledge, did not do exact justice even to his own institution, 
because I find that while you have this system of paying patients in 
the general ward, you have also got a system of careful inquiry into 
the circumstances of the patient, as I found in St. Luke's Hospital, 
even in the wards themselves, where they had a case only recently of 
a man who came in and declared that he was unable to pay anything, 
and representing himself to be without means, he got relief; but it 
was discovered after he had been in the hospital several weeks that 
he had means, through seeing who came to him, and watching the 
man ; and he was made to pay every single penny. So I think it is 
very probable that at the Presbyterian Hospital they have the same 
system. I believe they are continually on the watch to arrive at 
the facts, and if that is so, I venture to say, as a good friend and 
upholder of the medical profession, as a man who is immensely inter- 
ested in the hospitals as well as in the profession, that they have 
the best security possible in these hospitals. 



132 ROWE. 

Mr. Ryerson. — I would like to say one thing about our medical 
men, and that is this, we do not allow any outside medical men to 
treat patients in our hospital. I have always found that medical men 
were perfectly satisfied to treat a few patients fi^ee, and not only to 
treat a few patients free, but frequently to treat free those patients 
who are able to pay hospitals eight or nine dollars and able to 
do no more, and to rely only on patients who are apparently able 
to pay say fifteen or twenty dollars a week or more for separate 
rooms, for the payment of fees. Of course they would not do that 
if every man was allowed to practice in the hospital, because that 
would limit their field. 

The Chairman,— I am sorry that we have not time for further 
discussion on this matter, because there are one or two points, par- 
ticularly the relation of medical men to paid patients in hospitals, 
that are important, and it would be interesting to bring out the 
different methods that are pursued in different hospitals. A hospital 
whose chief purpose is medical education, having a staff selected 
from the teachers in a medical school, and the members of that staff 
having the sole privilege of placing pay patients in the institution, or 
at all events having the first privilege, is quite different from a hospital 
having no connection with any training institution, relying mainly 
upon its resident physicians for its medical attendance, and which 
allows any physician to send in pay patients and to attend them. 
The relations between the hospital organization and the medical 
staff appear to me to be quite different in these two cases. 



ISOLATING WARDS AND HOSPITALS FOR INFEC- 
TIOUS DISEASES. 

By G. H. M. Rowe, M. D., 

Medical Superintendent of the Boston City Hospital, 

The finding of the "Rosetta stone" unlocked the secret which the 
ages had thrown over Egyptian hieroglyphics. The discovery of 
the bacillus was the key to the mystery of the cause, development 
and spread of infectious diseases. The impossible became possible. 
The pathological laboratory has demonstrated that infection is a 
micro-organism whose characteristics are being gradually revealed. 



ISOLATING WARDS AND HOSPITALS FOR INFECTIOUS DISEASES. 1 33 

and, what is of greater importance, it has taught us the agents for its 
destruction. 

The physical laboratory has not exhausted the limits of the power 
and usefulness of electricity, nor has the pathological laboratory yet 
worked out the full scope of infection in its multifarious and far* 
reaching destructiveness. 

These investigations and the deductions from them will make the 
basis of future professional treatment and the management of infec- 
tious diseases, but the economic and social bearings of the problem 
demand study from other points of view. Time forbids a historical 
or statistical review, and I proceed at once to briefly work out a few 
hospital equations that are paramount in the management of infectious 
diseases. 

This audience, needs not to be told that on the first appearance of 
an infectious disease it should be immediately removed to a place of 
isolation, not only for its proper treatment, but for the protection of 
others. If the case appears in a home, probably an attempt will be 
made to isolate there, usually resulting in a separation that does not 
isolate. Epidemics are created by such futile attempts. Sanitary 
practice does not keep pace with sanitary knowledge. Not removing 
a person with an infectious disease to a hospital or some place secur- 
ing absolute isolation, should be held as a punishable offense against 
society. Public health will never be assured till an enlightened 
popular sentiment co-operates to this end. 

Every general or cottage hospital should have a suitable place to 
promptly isolate all cases of infection that may arise within its own 
walls. Infection, in this connection, includes not only eruptive fevers, 
but also all diseases liable to convey surgical infection. In recent 
years, whenever a general or well-appointed cottage hospital is built, a 
separate building is found among its resources for this purpose. But 
there are many pretentious hospitals having more than 100 beds for 
general medical and surgical diseases, founded twenty years ago, or 
even less, without such provision. The same is true not only in 
America but in England, even in London, owing to the original 
defective plan or want of the money necessary for the construction 
of such a building. There are scores of pretentious hospitals in the 
United States where provision for infectious cases cannot be found 
outside the buildings where such cases may arise. When an infected 
case appears, the usual policy is to temporize by placing it in some 
, part of the building supposed to be less exposed than the ward where 



134 ROWE. 

the case previously was assigned. This makeshift is never satis^c- 
tory, and if other persons escape, it is usually by a happy chance. 
No hospital of modem construction should for a moment hazard any 
compromise in providing proper isolation in a building for exclu- 
sive use of infectious cases. With such a buildmg properly equipped, 
and with a suitable ratio of intelligent nurses whose hospital life is 
regulated by discreet and rational rules, the management of infection 
becomes somewhat easier. In wards having a score or less of 
patients suffering with a variety of infectious diseases, the regulations 
demand great exactness. The problem becomes yet more difficult 
when the wards number from forty to fifty such cases. In municipal 
hospitab having several hundred beds, many infectious cases, elimi- 
nated from the regular medical and surgical wards, must be provided 
for. This aggregates quite an array of infectious cases, in one ward 
for men, another for women. Besides the complication of infection 
requiring the greatest skill, these wards are generally attended by 
the Visiting and House Staff, who are likely to have duties in other 
parts of the hospital. The relations of these wards to other parts of 
the house in the matter of domestic service, supplies, clothing, laun- 
dry work, and the infinite number of minute adjustments, all combine 
to exact the most judicious and vigilant regime. Many cities or large 
towns of from 8000 to 15,000 inhabitants have cottage hospitals which 
are forced to meet the requirements of their communities. They 
cannot select their cases, where public opinion is not rightly educated 
on such matters, and the hospital is apt to condone harmful admis- 
sions, under the delusion of keeping peace. Medical science demon- 
strates that public welfare makes imperative special, isolating wards, 
not only in municipal but in cottage hospitals. This is more easily 
accomplished in hospitals that are private corporations, but is difficult 
in hospitals dependent on municipal appropriations. 

There is a variety of practice about admitting to the wards con- 
nected with general hospitals, such infectious diseases as scarlet 
fever, diphtheria, measles, and the ordinary infectious diseases occa- 
sionally epidemic. But no hospital, either large or small, municipal, 
corporate, or cottage in its organization, should receive infectious 
fevers into its general wards. Is it absurd to state a rule so self-evi- 
dent? I have frequently seen, in this country, a case of scarlet fever 
or diphtheria simply removed from the other children by putting it 
in a room by itself — a mere pretense of isolation, I have also seen 
in a prominent London hospital with a medical school attached, 



ISOLATING WARDS AND HOSPITALS FOR INFECTIOUS DISEASES. 1 35 

cases of scarlet fever and diphtheria in beds contiguous to those of 
patients with ordinary medical diseases. Exclude infectious diseases 
from all general hospitals, unless provided with separate special 
buildings for each disease. These wards should be absolutely iso- 
lated by distance, with separate service, both nursing and domestic ; 
and the physicians and surgeons in charge, as well as the house staff, 
should have no active connection with the general wards. Every 
precaution should be taken to render the care and treatment, if not 
absolutely, yet practically, independent, so as to reduce the possi- 
bility of carrying infection to other parts of the hospital. With obvi- 
ous advantages, it is far from the ideal plan. The difficulties and 
dilemmas of infectious disease wards attached to a large hospital are 
so numerous that the wisest policy seems to forbid it, except as a 
relief for cases developing within its own walls. In large communi- 
ties, the only system that is beyond criticism is to make for infec- 
tious diseases a separate establishment, independent and isolated. 
Bear in mind in this discussion that cholera, typhus fever and small- 
pox are excluded. Obviously, from their deadly nature, these must be 
treated each in a hospital specially devoted to its care, isolated in 
location as well as classification, although not necessarily under diff- 
erent boards of government. It is comparatively easy to lay down 
dictums indicating the best method, but pernicious conditions exist 
in many American cities which complicate the problem. It is a 
lamentable fact that the cities in this country possessing accommo- 
dations for infectious diseases among the poorer classes, to say 
nothing of the " well-to-do," can be counted on the fingers of one 
hand. To the best of my knowledge, Boston is the only large city 
where a hotel guest or a citizen in good circumstances can obtain 
suitable accommodations in a hospital, if he is ill with diphtheria, 
scarlet fever or smallpox. In most cities the better class of corporate 
general hospitals absolutely refuse him admission. He is referred to the 
health authorities. What then? Generally the resources at its dis- 
posal are merely barracks or old buildings, diverted to hospital pur- 
poses after being abandoned as unsuitable for uses less humane. I do 
not forget the numerous cottage hospitals with special isolating wards 
which have sprung up within the past fifteen years in our more thrifty 
and enterprising towns. This indicates a growing intelligence in 
medical matters, and the possible advance to separate buildings. 

But it is in the larger municipalities where the proper accommoda- 
tions are most deplorably lacking. The situation is the more humil- 



1 36 ROWE. 

iating, considering how many American cities and towns erect new 
and pretentious hospitals at almost needless expense, on the best 
modern lines, while little or no progress is made towards establish- 
ing isolation hospitals for the poor, to say nothing of buildings to 
which the better class would resort We recognize the superior sys- 
tems employed in European capitals, especially in Germany, and also 
in the health districts of Great Britain, notably the urban, sanitary 
districts. 

Political methods, so rampant in municipalities, greatly affect sani- 
tation and public health, and too often prove a stumbling-block to 
progress. The present rapid strides in scientific, educational and 
industrial affairs, and in public works, absorb so much energy and 
capital that public sanitation will wait indefinitely unless the medical 
profession employs Wendell Phillips' favorite weapon, "Agitate, 
agitate ! " Optimists would fain believe that the trend of education, 
the truths of the laboratory, the altruistic spirit of the times, will 
eventually make clear to average intelligence the importance of 
having the proper means for stamping out the deadliest foe to public 
health. It is the duty of hospital workers and sanitarians not to 
cease forcing upon public authorities the necessity of intelligent action, 
until every municipality, through its public treasury, shall provide 
special hospitals always available for infectious diseases. Is it not 
the wisest policy to put such hospitals under the immediate control 
of the local board of health ? They have so close a connection with 
other vital matters properly belonging to health boards that it con- 
duces to unity of action to have the suppression of infection under 
one authority — a. practice that obtains in Great Britain. 

But what general plan shall be pursued for special infectious dis- 
ease hospitals, say in a city of about 500,000 inhabitants, with a total 
requirement of perhaps 250 beds ? 

The first step is a site sufficiently large for liberal distribution of 
buildings, reasonably easy of access, and yet well isolated from sec- 
tions thickly populated. In the present state of public opinion, if it 
is nof easy of access, it defeats its own ends. Smallpox, like cholera 
and typhus, should be provided for in a hospital by itself, and the 
opinion of so eminent an authority as Dr. Thorne Thome that a 
smallpox hospital should not be within a mile of an inhabited house 
is a wise and safe guide. As in Glasgow, smallpox might be cared 
for within the boundaries of an infectious group of buildings, but 
administered by itself and having no physical contact with the rest 



ISOLATING WARDS AND HOSPITALS FOR INFECTIOUS DISEASES. 1 3/ 

of the establishment. Other divisions should provide for the ordinary 
infectious diseases, each disease having its own buildings with divi- 
sions for each sex. Each building may be absolutely separate and 
yet be a component part of the whole. The group should have 
administration building, a domestic building, a service house con- 
taining the heating installation, laundry, mortuary, and a special 
home for nurses and the domestic service. Nurses, especially in 
infectious disease hospitals, should always be given quarters of their 
own in a building not occupied by patients, and of a quality to attract 
the class of women most desirable for hospital work. 

The wards should be of moderate size, not to exceed thirty beds. 
The number of buildings for each disease should be sufficient to 
allow one building, so to speak, to " lie fallow " for renovation and 
disinfection. This reserve is a large factor in reducing the mortality 
in an infectious disease hospital. This generous installation of site, 
buildings and appointments, is not always practicable, either from 
the topography of a city, an available site, or the financial condition 
of a municipality. Such establishments, we are happy to say, do 
exist. The Belvidere Hospital for Infectious Diseases, in Glasgow, 
Scotland, is a most notable example. It covers 31 acres of land, and 
has 35 buildings with accommodations for infection usually prevalent 
in a large city. No better argument for isolation hospitals can be 
adduced than a rehearsal of the experience of the health authorities 
of Glasgow in changing the most unhealthy city in Great Britain, 
with the largest mortality, into a clean healthful city with a low 
death rate. 

A more feasible but less perfect arrangement is a site in or near 
the thickly settled portions. Insure the best possible isolation by 
high walls and perfect administration. Provide separate administra- 
tion and service buildings, give each disease and sex its own wards, 
and keep the ratio of beds to patients as liberal as possible. Such 
provisions, intelligently planned and wisely administered, will afford a 
powerful weapon to crush out infection. Liverpool, a city especially 
exposed to infection, has an admirable instance of a hospital of this 
class, and so eminent an authority as Mr. Henry C. Burdett assures 
us that "on the whole, this hospital may fairly be regarded as one of 
the best arranged infectious hospitals yet erected. Considering the 
restricted site, the arrangements are most satisfactory." 

The opinion is gaining ground among hospital superintendents 
and sanitarians that large numbers of infectious cases cannot be 



138 ROWE. 

treated to the best advantage under one roof without increasing the 
mortality rate. This has been demonstrated in hospitals and institu- 
tions devoted to the care of sick children. The ideal way to treat a 
case of acute highly infectious disease would be to have two rooms 
which the patient should occupy alternately for twelve hours, with 
proper safeguards in all the conditions of transfer. The same law of 
rotation, with a larger proportion of time, would be admirable for the 
occupancy of infectious disease wards. Many small, isolated buildings 
on one site yield better results than a few buildings of larger size on 
a restricted site. Increased cost is an objection to this. Unfortu- 
nately, public opinion, squeamish and short-sighted in public sanita- 
tion, backed by legislators ambitious for low tax rates, and cajoled 
by the always-sensitive taxpayer, is an effective and potent obstruc- 
tion to the more intelligent methods. 

Fire departments recognize that it is the first five minutes that count, 
so the first case of infection is the most important one to fight. Dr. 
Thorne Thorne has made the most exhaustive study ever attempted 
on infectious disease hospitals, and he instances scores of examples 
to show that epidemics have been crushed by having the means to 
isolate the first case. He insists that such buildings should be 
constructed in non-epidemic times, rather than under conditions of 
panic, and that immediate and permanent usefulness of hospitals is 
impaired by hurried erection. 

In conclusion I am asked how the city of Boston ranks in the 
means for the suppression of infectious diseases. 

Boston has possessed since 1877 a smallpox hospital for 50 ward 
patients, and six rooms for private paying patients. By the irony of 
fate, the last private patient was a well-known Boston poet. The 
hospital is half a mile from the nearest habitation, located on an 
excellent site, well appointed for its purpose as most cottage hospit- 
als, which it resembles in external appearance. It is to-day, and has 
been every day during the last sixteen years, occupied by a man and 
his wife, both nurses experienced in the disease, and ready at all 
times to receive a patient. It has its special ambulance which can 
always be summoned by telephone, and a reserve of portable huts 
and protected nurses when many cases occur. Dr. McCollom, the 
city physician, confidently asserts that 150 small- pox patients can be 
properly provided for at forty-eight hours* notice. This again is a 
good illustration of Dr. Thome's proposition, and the suppression of 
smallpox in Boston, and its very low mortality, through a long series 
of years, is an object-lesson worth heeding. 



ISOLATING WARDS AND HOSPITALS FOR INFECTIOUS DISEASES. 1 39 

The Boston City Hospital has 480 beds distributed among eighteen 
wards, including a men's ward of ten rooms, each accommodating 
four cases either of erysipelas, cellulitis, pus in any form, or any 
uncleanly case arising within our own walls or from outside. There 
is also a ward containing twelve rooms, accommodating forty-eight 
women, which receives similar cases, including pelvic or puerperal 
septic cases. 

The hospital also has two other wards, one for scarlet fever and 
one for diphtheria, each having thirty-two beds for both free and pay 
patients. These are separate buildings, built in 1886, of high cost 
construction, and in air supply, heating and ventilation, service rooms 
and special appointments, equal to the best of modern hospital 
wards ; indeed, they are the most admirable of the hospital. In all 
respects they supply the same amount and quality of professional 
care, nursing and comforts afforded by any ward in the hospital, 
whether free or paying. The nursing is done by the nurses in the 
training school, and the seniors of the house staff are in turn isolated 
for attendance in the wards. 

These wards are administered by the strictest regulations, and are 
practically isolated, but their proximity to the general wards imperils 
others, and proves the correctness of my proposition, that no wards 
designed for infectious fevers from without should be an integral 
part of a large general hospital. In spite of every safeguard, and 
after allowing for sources of infection from ward visitors and the 

* 

dangers imminent to a hospital of 750 people, cases now and then do 
crop out that may fairly be attributed to the infectious fever wards. 
The labor involved in a large general hospital is always great and 
exacting. Ought it to be augmented by the strain of preventing the 
transmission of infection from special wards to the non- infectious 
wards? 

During the last seven years, 752 cases of scarlet fever and 2227 
cases of diphtheria have been treated in these wards. It has given a 
wide experience of the dangers of infectious disease wards on the 
grounds of a large general hospital, and teaches " how not to do it." 

This unhappy condition, I am glad to say, will soon be remedied. 
After a repeated and persistent course of education imposed by the 
hospital management upon the city authorities, Boston is construct- • 
ing a special hospital for infectious diseases, which I feel sure will 
be unrivaled in this country. The trustees already have $237,000 
solely for this purpose. This, however, will not complete it, and 



I40 



ROWS. 



$140,000 additional has been promised in the oext loan bill, making 
$377,000 for this special purpose. Contracts have been made for 
#203,000, and the buildings are well under way. Time forbids a 
descripiion of them, but they are in the best lines of modern hospital 
conslruction, and intended for 250 patients, at a cost of about S1500 
per bed. The plans and details are the result of much study by 
eminent authorities, and will give Boston a strong weapon for fighting 
infectious diseases. For the present it will be under [he management 
of the Boslon City Hospital, and will be administered in a manner 
equal, and we hope superior, to the general wards. The plan of these 
wards may be seen in the Boston Ciiy Hospital exhibit in the An- 
thropological Building. 

In the May number of The Forum the learned president of this 
Section, in an article on municipal sanitation, asks this question: 
" Where is the place to which a lady living in a boarding-house or 
temporarily stopping at a hotel could take her child atHicted with 
scarlet fever?" 

In Massachusett.s, the cities of Boston, Cambridge and Newton 
all possess such accommodations. Three other hospitals in New 
England have isolation disease wards either under construction or 
projected. The isolating wards of the Boston City Hospital alone 
have private rooms for eighteen paying patients at $15, $20 and 
$25 per week. Their accommodations, treatment, nursing and 
general care, including diet, compare well with that usually given 
medical and surgical paying patients in first-class general hospitals. 

Boston goes a step further. The hypothetical case of scarlet fever, 
and also any citizen, rich or poor, can have their clothing and all 
infected fabrics taken for purification to the new and well equipped 
sterilization house of the Board of Health, and returned, without 
charge. 

Hospitals are only one part of the splendid enginery demanded 
for working out the extermination of infectious diseases. I cannot 
forbear calling attention to the collateral means. There must be 
efficient local boards of health, co-operating with state boards, all of 
which are controlled by a cenlral national organization under the 
United Slates Government. The highest intelligence of expert sani- 
tarians would thus penetrate all communities and concentrate action 
on a common foe. 



L 



ABSONDERUNGSRAUME UND SONDERKRANKENHAUSER. I4I 



GRUNDZUGE FUR BAU, EINRICHTUNG UND VER- 

WALTUNG VON ABSONDERUNGSRAUMEN UND 

SONDERKRANKENHAUSERN Ft)R AN- 

STECKENDE KRANKHEITEN. 

FOR DEN VOM 12. BIS 18. JUNI, 1893, IN CHICAGO STAITFINDENDEN InTER- 
NATIONALEN "WOHLFAHRTS-KONGRESS ENTWORFEN VON 

Dr. Moritz Pistor, 

Geheimer Medizinalrath^ vortragender Rath im Koniglich Preussischen Ministe- 
rium der geistlichen^ Unterrickts- und Mtdizinal-Angelegenheiten in Berlin, 

Ordentliches Mitglied der Koniglich Preussischen Wissenschaftlichen Deputation 
fiir das Medizinalwesen ; ausserordentliches Mitglied des Kaiser lich deut- 
schen Gesundheitsamtes, 

Ehrentnitglied der G e sell sch aft fiir qffentliche Gesundheitspflege in England; 
korrespondirendes Mitglied der Schlesischen Gese Use haft fiir vaterl&ndische 
Kultur ; korrespondirendes Mitglied der Koniglich Belgischen Gesellschaft 
fiir offeniliche Gesundheitspflege, 

Meine Damen und Herren / Der ehrenvollen Aufforderung des 
General-Stabsarztes der Vereinigten Staaten, Dr. John S. Billings, 
Vorsitzenden der III. Seklion fiir Krankenhauswesen, Ausbildung 
von Krankenpflegerinnen, unentgeltiiche ambulatorische Kranken- 
behandlung und erste Hilfe fiir Verungluckte des internationalen 
Kongresses fiir Wohlthatigkeit, Gefangnisswesen und Wohlfahrts- 
Einrichtungen zu Chicago, dem Kongress meine Ansichten iiber 
Isolir-Raume und Isolir-Krankenhauser fiir ansteckende Krank- 
heiten vorzutragen, bin ich mit grosser Freude nachgekommen. 

Nach den Statuten des Kongresses III Nro. 13, stehen mir nur 
30 Minuten fiir die sehr umfangreiche Aufgabe zur Verfiigung; ich 
werde mich bemiihen, soweit moglich, in Kiirze diejenigen Siitze zu 
fassen, welche mir fiir die Beurtheilung der Bedingungen zur Unter- 
bringung von ansteckenden Kranken in gesonderten Raumen oder 
in Sonderkrankenhausern nach den neuesten Anschauungen und 
Erfahrungen wichtig erscheinen, und bitte die Versammlung, ein 
etwaiges Ueberschreiten der vorgeschriebenen Zeit ebenso zu ent- 
schuldigen, wie mit Riicksicht auf die Kiirze derselben das Zusam- 
mendrlingen des Materials und eine etwa liickenhafte Behandlung 
desselben nachsichtig zu beurtheilen. 



142 PISTOR. 

Einleitung, 

Mitmenschen, die an ansteckenden Krankheiten litten,suchteman 
schon im grauen Alterthum von den Gesunden abzusondern ; es sei 
nur an die Hauser fur Aussatzige erinnert. Dieser Grundsatz hat 
sich erhalten und findet einen umfangreicheren Ausdruck in der 
Errichtung von Pesthausern wahrend des Mittelalters. Mehr und 
mehr hat im Laufe der Zeit die Ansicht sich befestigt, dass es fur 
eine grossere Anzahl von ansteckenden Krankheiten im Interesse 
des Gemeinwohles erforderlich ist, die von solchen Krankheiten Be- 
fallenen von ihren Mitmenschen moglichst abzusondern, um der Ver- 
breitung von iibertragbaren Krankheiten mit Erfolg entgegentreten 
zu konnen. Heute sind alle Hygieniker dariiber einig, dass in dieser 
Absonderung eines der wichtigsten Schutzmittel zur Beschrankung 
der Verbreitung infektioser Krankheiten liegt. Darauf weisen auch 
die Gesetzgebungen aller Kuhurlander hin, indem dieselben bald 
strenger, bald weniger streng die Unterbringung von an ansteckenden 
Krankheiten leidenden Personen, welche in der eigenen Wohnung 
nicht in geniigender Weise abgesondert werden konnen, in Sonder- 
Krankenhausern fordert. Wen die beziiglichen Bestimmungen fiir 
die einzelnen Lender interessiren, den verweise ich auf den trefflichen 
Bericht des Professor Dr. F. Felix auf dem VI. internationalen Kon- 
gress fiir Hygiene und Demographie zu Wien im Jahre 1887 " Ueber 
die Nothwendigkeit und Anlage von Isolir-Hospitalern/' XV. Thema, 
Heft 15 der Referate. 

Historisch sei noch bemerkt, dass 1746 in London das erste Blat- 
tern-Absonderungshaus errichtet worden ist; welches bis auf den 
heutigen Tag, wenn auch wesentlich erweitert und inszwischen raum- 
lich verandert, fortbesteht. 

Im Jahre 1802 wurde das London Fever Hospital, zunachst mit 
18 Betten, ebenfalls aus freiwilligen Beitragen hergestellt, in Gray's 
Inn eroffnet. Seither sind in alien Kulturstaaten Absonderungs- 
hauser eingerichtet und in Amerika, Deutschland, Danemark, 
England, Frankreich, Italien, Skandinavien in grosserer Anzahl in 
Betrieb gesetzt worden. Wie hoch sich die Zahl jener Hauser in 
den einzelnen Landern zur Zeit belauft anzugeben, ist mir nicht 
moglich. 

Welche Kranken sind abzusondern ? 

Von Eintritt in die enger begrenzte Aufgabe ist noch die Frage zu 
erortern, welche Kranken sollen abgesondert werden? 



absonderungsraume und sonderkrankenhauser. 143 

Allgemein wird verlangt, dass die an Cholera, Pocken, Fleckfieber, 
Gelbfieber und Pest Leidenden von anderen Kranken und Gesunden 
getrennt werden miissen. Ich kann nicht umhin hier im Gegensatz 
zu einzelnen Autoren darauf hinzuweisen, dass meines Erachtens 
Cholerakranke bei gehoriger Vorsicht allerseits sehr gut mit anderen 
Kranken zusammengelegt werden konnten, wenn nur zuverlassig 
dafiir gesorgt wird, dass die Ausleerungen der Kranken von ande- 
ren Kranken fern gehalten werden. Der Umstand, dass die Cholera 
nur durch die Ausleerungen der Kranken nach den heutigen An- 
schauungen, sofern dieselben virulente Kommabazillen enthalten, 
ubertragen wird, lasst eine Trennung dieser von anderen Kranken 
Oder Gesunden iiberfliissig erscheinen. Ich fiir meine Person spreche 
mich dessenungeachtet fiir eine Isolirung von Cholerakranken in 
eigenen Raumen oder Hausern aus : 

1, weil die Fernhaltung der Ausleerungen von anderen Kranken 
seitens des Pflegepersonals mirzweifelhaft bleibt, beigrossen Cholera- 
Epidemien wird man selten selbst in grosseren, geschweige denn in 
kleineren Ortschaften und auf dem Lande iiber ein auch nur annah- 
erend zuverlassliches Pflegepersonal verfiigen konnen; 

2, weil der Anblick eines Cholerakranken ein so erschrecklicher 
ist, dass man denselben anderen Mitkranken ersparen soil. 

Inwieweit die iibrigen Infektionskrankheiten in Betracht zu ziehen 
seien, dariiber gehen die Ansichten auch auseinander. Es diirfte 
indessen die Forderung wohl keinem ernsten Widerspruch von fach- 
wissenschaftlicher Seite begegnen, das Diphtherie, sowie Scharlach- 
Kranke der Absonderung unterworfen werden, Einzelne Landes- 
gesetzgebungen, zum Beispiel diejenige Englands, verlangen auch 
die Unterbringung der an Rose und Keuchhusten Erkrankten in 
Sonder-Krankenhauser. Fiir Gebarhauser muss die Absonderung 
der an Kindbettfieber leidenden Frauen von den iibrigen Insassen 
unbedingt verlangt werden. 

Dagegen scheint es mir zu weit zu gehen, wenn auch Masern- 
kranke in Hospitalern und so weiter abgesondert werden sollen; fiir 
solche Kranke wird eine Absonderung wohl nur unter den ungiin- 
stigsten ausseren Verhaltnissen zu fordern sein. Aehnliches gilt 
meiner Ansicht nach fiir den Keuchhusten. 

Darmtyphus und Ruhr, welche lediglich durch die Ausleerungen 
verbreitet werden, bediirfen selbst im Falle einer grosseren Verbrei- 
tung und bei heftigen Erkrankungsformen keiner Absonderung, 
sobald fiir Unschadlichmachung und Beseitigung der Ausleerungen 
der Kranken in zuverlasslicher Weise Sorge getragen wird. 



144 PISTOR. 

Unter alien Umstanden wird man bei jeder Ueberf iihning von an 
den genannten Krankheiten leidenden Personen in ein Krankenhaus 
zwei Punkte nicht ausser Acht lassen diirfen: 

1, das Gefiihl der Angehorigen soweit das Gemeinwohl dies 
gestattet ist zu schonen, damit die Abneigung gegen die Verpflegung 
in ofTentlichen Absonderungs-Einrichtungen bei der Bevolkerung 
nicht vermehrt wird ; 

2, durch zu weitgehende Forderungen tritt eine Erhohung der 
ofTentlichen Ausgaben ein, welche ebenfalls der Sache selbst leicht 
nachtheilig werden kann. 

Art der Absonderung. 

In welcher Weise soil nun die Absonderung stattfinden ? Kann 
man vom Standpunkte der ofTentlichen Gesundheitspflege fordem, 
dass jede Gemeinde, gleichviel ob gross oder klein, Absonderungs- 
raume oder gar Absonderungs-Krankenhauser fiir ansteckende 
Kranke der genannten Art schafTt ? Darauf diirfte zu bemerken 
sein, dass unter Umstanden, zum Beispiel beim plotzlichen Auftreten 
von Cholera, beim Ausbruch von Fleckfieber, Pocken, Gelbfieber 
und Pest, unbedingt Absonderungsr'aume und sei es auch nur in 
Form von Zelten oder Einzelzimmern geschafTen werden miissen. 
Dass kleinere Gemeinden dauernd derartige R'aume bereit stellen 
oder gar besondere Krankenhauser fiir diesen Zweck errichten, kann 
nicht verlangt werden ; es wiirde das eine finanzielle Belastung sein, 
die kleine Gemeindewesen nicht zu tragen vermogen. Wohl aber 
konnen und sollen Gen\einden von 50,000 Seelen und mehr derartige 
Einrichtungen schafTen, welche in gewohnlichen Zeiten zur Auf- 
nahme von an Scharlach, Diphtherie und so weiter Erkrankten 
benutzt werden konnen, beim Ausbruch der Landseuchen, Cholera, 
Pocken und so weiter geraumt, desinfizirt und fiir die Aufnahme 
der an der hereingebrochenen Epidemic Erkrankten hergerichtet 
werden. Sollte eine Ortschaft iiber 50,000 Seelen aus finanziellen 
Griinden ausser Stande sein, ein Sonderkrankenhaus zu errichten, 
so wird man sich damit begniigen miissen, bei dem vorhandenen 
allgemeinen Krankenhause Absonderungsraume, in Gestalt beson- 
derer Zimmer, oder einer oder mehrerer Baracken, einzurichten. 
Stadte von mehr als 100,000 Seelen und so grosse Gemeinde- 
verb'ande deren einzelne Ortschaften nahe bei einander gelegen sind, 
konnen und miissen Absonderungs-Krankenhauser einrichten. 
^ Solche Hauser sollen niemals fiir eine zu grosse Anzahl von Betten 



ABSONDERUNGSRAUME UND SONDERKRANKENHAUSER. I45 

vorgesehen sein und miissen entsprechend der Belegung, welche 
meines Erachtens 300 Betten nicht iibersteigen sollte, geniigend mit 
Arzten und Pflegepersonal versorgt sein ; wenn 50 und hochstens 70 
Kranke auf einen Arzt und 2-3 Warter zahlen diirfen, dann wird 
denselben im Allgemeinen geniigende Pflege zu Theil werden. Eine 
Anzahl von icx> Betten fiir einen Arzt erscheint schon etwas zu hoch 
gegriffen, weil Kranke solcher Art meist Arzt und Pflegepersonal 
sehr in Anspruch nehmen. 

Wir wenden uns nun zunachst dem Bau von Absonderungshausem 
zu, werden dann die Absonderungsraume in allgemeinen Kranken- 
hausem und zuletzt die beweglichen Baracken besprechen. 

Bau von Sonder-Krankenhdusem und Sonder-Rdumen, 

Absonderungs-Krankenhduser sollen, damit sie ihren Zweck 
erfiillen, fern von ' bewohnten Gebauden, doch auch nicht zu fern 
von der Stadt errichtet werden. Man darf betreffs der Entfemung 
von menschlichen Wohnungen nicht zu Ungstlich sein, wenn man 
die Beforderung von Kranken aus der Stadt in das Absonder- 
ungshaus nicht unendlich erschweren und damit die Absonderung 
selbst bei der Bevolkerung missbillig machen will. Es leidet der 
Kranke unter einem langen Transport im bequemsten Kranken- 
wagen, und dadurch wird das berechtigte Gefiihl der Angehorigen 
verletzt. Nach meinem Dafiirhalten wird es geniigen, wenn man 
Isolirhauser in einer Entfernung von etwa 100 Metern von mensch- 
lichen Wohnungen anlegt und zwar, soweit es moglich ist, auf 
einem etwas erhohten Gelande, welches den Winden freies Spiel 
gestattet, damit ein steter Luftwechsel auch um das Gebaude statt- 
finden kann. Eine grossere Entfernung von bewohnten Gebauden 
kann abgesehen von Pesthausern nur fiir Pockenhauser in Betracht 
kommen. Fiir Cholera und Fleckfieber, sowie die sonst erwahnten 
ansteckenden Krankheiten ist bei einiger Aufmerksamkeit im Betriebe 
eine Uebertragung der Krankheitskeime in die Nachbarschaft ledig- 
lich durch die Luft nicht zu furchten. Dafiir muss allerdings Sorge 
getragen werden, dass zwischen dem Isolirhause und dem nahege- 
legenen zum Aufenthalt fiir Menschen dienenden Hausem keinerlei 
Personenverkehr stattfindet. Zur richtigen Wilrdigung der An- 
steckungsgefahr muss man die Thatsache in Erwagung ziehen, dass 
Uebertragungen selbst der kontagiostesten Infectionskrankheit, des 
Fleckfiebers, in den allgemeinen Krankenhausern, welche mit 
Absonderungsbaracken oder Absonderungszimmern versehen sind. 



146 PISTOR. 

bei der Haufigkeit dieses Verhaltnisses verhaltnissmassig selten in 
neuerer Zeit vorgekommen sind,seitdem man dafiir mehr und mehr 
Sorge getragen hat, dass fiir die an Fleckfieber Erkrankten beson- 
deres Pflege- und Dienstpersonal sowie eine eigene Verpflegungs- 
einrichtung vorhanden ist. Der Personenverkehr dient stets der 
Uebertragung aller jener hicr in Betracht kommenden Krankheiten 
in erster Linie. 

Die Grosse des Baugrundstiickes soil nach Ansicht vieler, beson- 
ders englischer Autoren so bemessen sein, dass auf jedes Kranken- 
bett 200 Quadratmeter Grundsliicksflache entfallen. Ich verkenne 
gewiss die Berechtigung eines solchen Wunsches im gesundheit- 
lichen Interesse zuletzt, kann aberdie Besorgniss nicht unterdriicken, 
dass diese Forderung zu weit geht und deshalb selten erfiillt werden 
wird ; es diirften 150 Quadratmeter Bauflache fiir jedes Bett aus- 
reichen, um auch noch einen Garten fiir die Genesenden um das 
Hospital zu schaffen. Ist anzunehmen, dass in kurzer Zeit die 
Bevolkerung sich an dem in Frage kommenden Ort erheblich ver- 
mehren wird, dann empfiehlt es sich allerdings, eine grossere Grund- 
flache fiir jedes Bett in Aussicht zu nehmen, damit bei Zunahme der 
Bevolkerung baldmoglichst eine Erweiterung des Absonderungs- 
Lazarettes stattfinden kann. 

Fiir ausgedehnte Gemeindewesen iiber 50,000 Seelen erscheint es 
trotz der voraussichtlich schnellen Bevblkerungszunahme kaum 
rathsam, dem etwaigen Bediirfniss durch Erweiterung eines Baues 
Rechnung zu tragen, vielmehr zweckentsprechender, in solchen 
Fallen die Anlage mehrerer excenjrisch belegener Sonder-Kranken- 
hauser nach verschiedenen Stadtseiten ins Auge zu fassen, um einen 
zu weiten Transport der Erkrankten zu vermeiden. 

Baugrund. 

Soweit es die Verhaltnisse gestatten, wird man einem trocknen, 
durchlassigen Untergrund, als Baugrund den Vorzug geben; ist 
roan auf feuchtes Gelande angewiesen, so sind diejenigen Vorkeh- 
rungen zu treffen, welche fiir die Trockenlegung eines solchen Bau- 
grundes durch Drainage, Isolirschichten in den Kellerraumen und 
dergleichen mehr erprobt sind. Diese jedem Sachverst'andigen 
bekannten Dinge hier bis ins Einzelne zu erortern, halte ich nicht 
fiir erforderlich, da sie in nichts von den allgemeinen Vorschriften 
iiber Trockenlegung des Baugrundes fiir bewohnte Gebaude, ins- 
besondere auch fiir allgemeine Krankenh'auser verschieden sind. 



ABSONDERUNGSRAUME UND SONDERKRANKENHAUSER. I47 

Auch iiber die Orientirung der einzelnen Gebaude erscheint mir 
eine besondere Auseinandersetzung uberfliissig, man wird dieselbe 
nach den klimatischenund sonstigen Verhaltnissen zu w'ahlen haben. 
Wie bekannt, sind die Ansichlen in dieser Beziehung getheilt ; nach 
meinem Dafurhalten wird man in kalten Landern die Krankenzimmer 
gegen Siiden, bei gemassigtem Klima nach Osten und in heissen 
Gegenden nach Norden legen, um die Leidenden vor iibermassig 
heissen Zimmern zu schiitzen. Das etwa lastige Sonnenlicht lasst 
sich durch Vorhange von Stoff, Laden, Jalusien und dergleichen 
mehr abhalten, und Kalte durch zu rechter Zeit und in geeigneter 
Weise bewirkte Heizen bewaUigen ; von der Sonnenhitze durch- 
gliihete Zimmer sind bei selbst vorzUglichen LUftungs-Einrichtungen 
schwer kiihl und fiir den Kranken behaglich zu machen. 

Dass die gesammte Anlage durch eine Umwahrung begrenzt wird, 
dass der Garten mit hochstammigen B'aumen zur Erzielung von 
Schatten besetzt wird, sei nur erw'ahnt. 

Bei dem Bau einer derartigen Einrichtung ist darauf RUcksicht 
zu nehmen, dass die fiir das arztliche und Pflegepersonal bestimmten 
Wohn- sowie die Wirthschaftsraume entweder in einem besonderen 
Gebaude untergebracht, oder aber durch eine abschliessende Wand 
von den Krankenraumen vollst'andig getrennt werden ; wo es die 
Verhahnisse gestatten, sind auch die Wirthschaftsraume nicht mit 
den Wohnstatten unter einem Dach anzulegen, damit Arzte und 
Pfleger nicht durch Kiichenlarm und KUchendunst geslort und be- 
lastigt werden. 

Bauart. 

Was nun die Art der AusfUhrung im Allgemeinen anbelangt, so 
muss man unterscheiden zwischen der eingeschossigen und zwei- 
geschossigen Baracke, einem Bau ohne Seiten-Korridor, vielfach 
auch in Holz oder Fachvverkbau ausgefdhrt, und dem massiven 
Pavilion oder Block mit Seiten-Korridor. 

Ich gebe der eingeschossigen, in festem Material hergestellten 
Baracke vor alien anderen Einrichlungen fiir alle ansteckenden 
Krankheiten den Vorzug, weil diese Art des Baues besser wie 
jede andere eine voUstandige Absonderung auch der einzelnen an- 
steckenden Krankheiten unter sich gestattet. Bei grosseren Anlagen 
kommt es doch wesentlich darauf an, dass die Kranken je nach der 
Art der Erkrankung in eigenen R'aumen, welche lediglich solche 
Kranke aufnehmen, untergebracht werden. Nur im Nothfall kann 



148 PISTOR. 

es zugelassen werden, dass Kranke, welche an verschiedenen an- 
steckenden Krankheiten leiden, zusammengelegt werden; immer 
muss auch dann mit Vorsicht und Sorgfalt ausgewahlt werden; so 
sind zum Beispiel Blattern- und Fleckfieberkranke stets zu isoliren, 
weil die Uebertragung dieser Krankheiten zu leicht stattfindet. 
Man wird daher darauf Bedacht nehmen miissen, fiir die in den 
einzelnen Landern oder Landestheilen am haufigsten vorkommen- 
den ansteckenden Krankheiten Einzelhauser oder doch mindestens 
abgesonderte Einzelraume herzustellen. Wo, wie in Norddeutsch- 
land, Diphtherie und Scharlach niemals vollkommen verschwinden, 
wird man fiir diese Krankheiten je einen Sonderraum in grosseren 
Gemeindewesen herstellen ; wo Fleck- und Riickfallfieber endemisch 
sind, in Landern, in welchen die Pocken noch haufig verbreitet 
auftreten, sind Sonderhauser fiir solche Kranke ein unabweisbares 
Erforderniss. Das schliesst nicht aus, dass diese Sonderhauser, 
selbstredend nach gehoriger Reinigung, fiir andere Zwecke nach 
dem Erloschen einer Epidemie benutzt werden konnen. 

Die einzelnen Baracken oder Pavilions miissen in gehoriger Ent- 
fernung, mindestens 30 M. von einander und von Wohn- und Wirth- 
schaftsgebauden errichtet werden ; ein solcher Abstand diirfte im 
Allgemeinen zur Verhiitung von direkter Ueberfiihrung von Infek- 
tionstragern geniigen. Lassen sich nach dem zu Gebote stehenden 
Baugrunde grossere Abst'ande erreichen, so kann dies nur giinstig 
wirken. Die einzelnen Baulichkeiten sind unter sich, mit den 
Wohn- und Oekonomiegebauden durch bedeckte, aber nicht von 
beiden Seiten geschlossene Gange zu verbinden, um Arzte, Pfleger 
und Bedienstete, insbesondere der Kiiche, sowie auch die Speisen 
beim Durchtragen zu den einzelnen Kranken-Abtheilungen gegen 
die Ungunst des Wetters zu schiitzen. 

Fiir die zweigeschossige Baracke und den massiven, stets mehr- 
geschossigen Pavilion bleibt die Fundamentirung abgesehen von 
angemessener Verstarkung dieselbe, wie bei der eingeschossigen 
Baracke ; die Gebaude sind unter alien Umstanden zu unterkellem 
und wo es der Baugrund erfordert, in der Fundamentirung mit 
Isolirschichten zu versehen. 

Wdnde, 

Die Wande sind auch bei der eingeschossigen Baracke nur im 
Nothfall in Holzbau herzustellen ; im Allgemeinen werden die 
Wande auch im Baracken-System jetzt in Stein oder anderem festen 



ABSONDERUNGSRAUME UND SONDERKRANKENHaUSER. I49 

Material aufgefiihrt. In neuester Zeit hat man Eisenkonstruktion 
gewahlt, auch Gipsdielen zum Beispiel in der Krankenabtheilung 
des Instituts fiir Infektionskrankheiten in Berlin. Im Uebrigen 
konnen gute Backsteine, Moniermaterial und dergleichen mehr 
Verwendung finden. 

Wesentlich bleibt fiir alle Konstruktionen, dass die Innenseite 
sammtlicher Wande des Gebaudes durchweg, nicht allein in den 
Krankenraumen, moglichst glatt gehalten ist. Zu diesem Zweck 
kann man dieselben entweder mit mehreren Schichten Oelfarbe 
iiberziehen oder mit Mettlacher Fliesen bedecken, welche mit Por- 
zellankitt gefugt sind, oder aber ganz und gar aus glasirten 
gebrannten Steinen auf bauen, deren Fugen wiederum durch Emaille- 
farbe oder Kitt gedeckt und glatt gemacht sind ; so ist zum Beispiel 
die „New Royal Infirmary" zu Liverpool, eroffnet 1891, durchweg 
in Krankenraumen jeglicher Art, Korridoren, Kellern und Kiichen 
gebaut. 

Sind die Wande auf die eine oder andere Weise geglattet, so 
werden dadurch ^e durch Vermeidung aller Ecken an dem Zusam- 
menstossen der Wande unter einander mit der D.ecke und mit dem 
Fussboden Staubablagerungen thunlichst verhiitet und lassen sich. 
wenn sie eingetreten sind, in leichtester Weise entfernen. Um die 
Ecken in den Raumen zu vermeiden, rundet man die Wande sowohl 
an der Stelle, wo sie mit dem Fussboden, als auch mit der Decke und 
unter sich zusammenstossen ab ; statt der Ecken entstehen so ausge- 
hohlte glatte Kehlungen. 

Ein Anstrich, der sich in dem Institut fiir Infektionskrankheiten 
bewahrt hat, besteht aus einer starken Grundirung der Gipsdielen- 
wande in Oelfarbe, auf welche dann Emaillefarbe in mehreren 
Schichten aufgetragen worden ist. 

Fussboden, 

Auch der Fussboden muss moglichst glatt sein. Zu diesem 
Zweck wird von der Mehrzahl der Autoren festgefugtes Eichen- 
Riemenparquett empfohlen. Felix und andere Autoren sprechen 
sich dagegen aus, weil die Fugen niemals so dicht seien, dass der 
Staub nicht einzudringen vermoge. In englischen Sonderkranken- 
hausern wird das Bohnen eines solchen Fussbodens ebenso wie der 
Oelanstrich vermieden und der Boden moglichst haufig nass aufge- 

wischt. 
Wenn man Holzfussboden iiberhaupt wahlt, so scheint mir das 



1 50 PISTOR. 

Vermeiden des Bohnens wenigstens nbthig, damit ein haufiges Auf- 
nehmen des Staubes mit feuchten Tiichern stattfinden kann. 

Urn jenen Uebelstanden von Grund aus zu begegnen, ist wieder- 
holt vorgeschlagen und ausgefiihrt worden, die Herstellung des 
Fussbodens aus Terrazzo, Mettlacher Fliesen und dergleichen. In 
letzterem Falle ist die K'alte des Fussbodens nicht zu untersch'atzen 
und wird man sich, urn den Nachtheilen, welche daraus fiir die 
Kranken entstehen, vorzubeugen, entschliessen miissen, solche stein- 
artigen Fussboden nur unter der Bedingung anzulegen, wenn der- 
selbe durch Fussbodenheizung erwarmt werden kann ; ein Punkt der 
indessen der reiflichen Ueberlegung nach den bisher gemachten 
Erfahrungen noch bedarf. 

Grosse des Einzelbaues, 

Was nun die Grosse der Baracke selbst anbelangt, so soil dieselbe 
fiir mindestens 10 Betten ausreichen, aber auch den Belagraum fiir 
24 Betten nicht iiberschreiten. Es scheint nicht zweckm'assig, eine 
noch grossere Anzahl Schwerkranker in einen Raum zu bringen und 
wiirde es nach meinem Dafiirhalten, falls nicht der Kostenpunkt 
dabei in Frage kommt, sich immer empfehlen, hochstens 20 Kranke 
in einen Raum zu bringen. 

Der fiir jedes Bett erforderliche Luftraum soil nach englischen 
Forderungen 60 Kubikmeter betragen, so dass also bei einer Hohe 
von 4J Metern nach Abzug von Ofen- und Nebenplatzen fiir jedes 
Bett ein Flachenraum von 13 J Quadratmetern nothig sein wiirde. 
Dabei verlangt Felix noch eine Lufterneuerung von 60 Kubikmetem 
in der Stunde. Englische Isolirhauser gewiihren bei reichlicher 
Liiftung sogar 70 Kubikmeter Raum (Fever Hospital in Leicester, 
Liverpool und Glasgow, sowie einzelne Absonderungshauser in 
London). Wo es die Verhaltnisse gestatten, kann es nur dankbar 
anerkannt und mit Freuden begriisst werden, wenn dem Kranken 
ein reichlicher Kubikraum an Luft gewahrt und letztere ausserdem 
oft erneuert wird. Es darf indessen nicht verkannt werden, dass die 
Forderungen von immer grosserem Luftraum fiir den einzelnen 
Kranken eine grosse finanzielle Belastung der Gemeinden bilden, 
und, wenn es gelingt, mit etwas weniger Kubikraum auszukommen 
und die Kranken durch reichliche Zufiihrung von frischer Luft dabei 
schadlos zu halten, so kann das fiir die gesammte Hospitalfrage nur 
giinstige Folgen haben. 



ABSONDERUNGSRAUME UND SONDERKRANKENHAUSER. I5I 

Lufiung, 

In der Krankenabtheilung des Berliner Institutes fiir Infektions- 
krankheiten hat man sich geniigt, fiir jedes Bett 40 Kubikmeter 
Luft zu gewahren, hierbei aber durch vortrefflich wirkende Entluf- 
tungs-Vorrichtungen eine Lufterneuerung von 80 Kubikmetern fiir 
jedes Bett in der Stunde, noch bei niedrigster Temperatur der 
Aussenr'aume, erlangt. 

Fiir die Entliiftung der Raume in der eingeschossigen und dem 
Dachstock der zweigeschossigen Baracke sorgen gegeniiberliegende 
nicht zu kleine Fenster in Verbindung mit dem Dachreiter auf der 
First des Daches, welcher selbstverstandlich so eingerichtet sein 
muss, dass die Kranken nicht durch Zugluft belastigt werden, in 
ausgiebigster Weise. 

Neben dieser natiirlichen Frischluftzufiihrung hat man fast iiberall 
zu kiinstlichen Unterstiitzungsmitteln gegriffen und die verschieden- 
sten Methoden dabei zur Anwendung gebracht. Die besten Anlagen 
der Art sind stets mit der Heizung verbunden, so dass die zuge- 
fiihrte Menge frischer Luft nich kalt, sondem vorgewarmt, in die 
Krankenraume hineinkommt. Ich kann hier nicht auf die verschie- 
denen Liiftungsvorrichtungen naher eingehen, ohne die mir nach 
der Aufgabe und namentlich nach der zur Verfiigung stehenden Zeit 
gesteckten Grenzen weit zu iiberschreiten, muss mich vielmehr auf 
die Ausserung beschranken, dass fiir Isolir-Spit'aler und Isolirrau- 
men nur die bewahrtesten Lufterneuerungsanlagen genommen werden 
sollten ; gerade in diesen Fallen ist eine zuverlassige Lufterneuerung 
das dringendste Erforderniss. 

Dass man sich in England und Russland mit Vorliebe der ein- 
fachen Luftkammern bedient, dass in Deutschland das Pulsions-Sys- 
tem verbunden mit der Heizung, vielfach in Anwendung kommt, die 
Meidingerschen und Bohmeschen Mantelofen, sowie andere ahnliche 
Vorrichtungen ihre Verwendung gefunden haben, sei kurz ^wahnt. 

Das Dach sei leicht aber fest fiir jede ein- wie zweigeschossige 
Baracke. Der Dachreiter muss vorsichtig so konstruirt sein, dass 
durch denselben reichlich Luft zugefiihrt werden kann, aber die 
eindringende Luft nicht zu schnell in den Krankenraum hinein- 
gelangt ; dies ist durch zweckmassige Anlage der Dachreiter und 
verstellbarer Luftklappen sehr gut zu erreichen. 



152 PISTOR. 

Raumveriheiiung^ Nebenraume. 

In jeder eingeschossigen, wie im Obergeschoss einer zweigeschos- 
sigen Baracke fur 10 bis 20 Betten muss ausser dem Krankensaal 
ein Abort, ein Baderaum, ein Warterzimmer, eine Theekiiche und 
wo moglich ein oder zwei Raume f iir Einzelkranke oder f iir ansteck- 
ungsverdachtige Falle, welche der Absonderung bediirfen, vorhanden 
sein. Die Abortvorrichtungen, welche je nach den Verhaltnissen 
an Kanalisation und Wasserleitung anzuschliessen sind oder aber 
Tonnen- bezw. Kubel-System haben sollen, sind mit einer Einrich- 
tung an geeigneter Stelle zu verbinden, welche bei bestimmten 
Krankheiten das Kochen gefahrlicher Ausleerungen und damit die 
griindlichste Vernichtung von Krankheits-Keimen ermoglicht. 

Die zu diesem Zwecke nach dem Vorgange der bei dem Auftreten 
der Cholera in Petersburg nach einem 1887 von Wassiljew gemach- 
ten Vorschlage von einem Herrn Sangalli gelroffenen Einrichtungen 
sind auf Rudolph Virchow's Befiirwortung von dem Verwaltungs- 
Direktor des Berliner st'adtischen Krankenhauses Moabit, Merke, 
1892 in sehr einfacher Form modifizirt worden und haben sich 
wirksam erwiesen; Merke beschreibt seine Einrichlung in der Ber- 
liner Klinischen Wochenschrift, Jahrgang 1892, Nro. 38, etwa folgen- 
dermassen : 

Statt des sonst vorhandenen Ausgusses fur Wirthschaftswasser 
etc. neben dem Closet waren schon friiher zwei nebeneinder liegende 
gusseiserne, innen emaillirte viereckige Becken angebracht worden, 
von denen das eine, fiir die Aufnahme der Excremente bestimmte 
bedeutend tiefer war, wie das daneben gelegene flachere. Beide 
communicirten durch einen zwischen dem Boden des flachen Beckens 
und der gemeinschaftlichen Scheidewand gelegenen Spalt mit einan- 
der, so dass Fiussigkeiten, die in das flache Becken gegossen wurden, 
durch ^liesen Spalt in das tiefer gelegene benachbarte abfliessen 
mussteiii Letzteres hat in der Mitte seines Bodens eine grosse Ab- 
flussofTnung, die durch ein schweres Metallventil verschliessbar ist ; 
das Ventil selbst ist durch eine den Rand des Beckens weit iiber- 
ragende runde Metallstange, die mit einem Handgriff versehen ist, 
leicht zum Zweck des Oeffnens zu heben. Ueber dem flachen 
Becken befinden sich Kalt- und Warmwasser-Auslasshahne. 

In dieser Einrichtung waren bisher alle verdachtige Enileerungen 
der Kranken etc., auch im Sommer 1892 Cholera-Dejektionen, letz- 
tere unter Zusatz von Kalkmilch desinfizirt worden, bevor diese 
Substanzen in die Kanale abgelassen wurden. 



absonderungsraume und sonderkrankenhauser. 153 

Um dieselbe Vorrichtung zum Kochen von Cholera-Excrementen 
brauchbar zu machen, wurde von der in jeder Baracke des st'adt- 
ischen Krankenhauses Moabit vorhandenen Dampfleitung ein Kupfer- 
rohr abgezweigt und in das tiefe Ausgussbecken so geleitet, dass es 
zweimal in Spiral wind ungen auf dem Boden des Beckens um die 
AbflussofTnung herumgefuhrt wurde, wahrend das Becken selbst 
durch einen abhebbaren Doppeldeckel oben verschlossen werden 
konnte. Folgendes Ergebniss wurde erzielt : 

1. Das Kochen des im Becken vorhandenen Gemenges von 
Excrementen und Kalkwasser kommt je nach der Menge der vor- 
handenen FlUssigkeit mit Leichtigkeit in 4 bis 10 Minuten zu 
Stande ; 

2. die mit dem Kalkwasser gemengte FlUssigkeit schaumt beim 
Kochen sehr stark auf ; 

3. beim Kochen der Facalmassen mit Kalkwasser entwickelt sich 
ein penetranter, ausserst iibler Geruch. 

Das Abkochen der Facalien war somit erreicht, aber der dabei 
entstehende sehr iible Geruch niusste vermieden oder beseitigt 
werden. Dies gelang durch Zusatz einer 5 prozentischen Losung von 
iibermangansaurem Kali statt der Kalkmilch zu den Dejektionen im 
Abflussbecken. 

Fiir die beim Kochen sich entwickelnden Wasserdampfe ist auf 
dem Ausgussbecken ein Abdunstrohr aufgesetzt, das Uber Dach 
gefiihrt ist. 

Bacteriologische Versuche haben ergeben, dass das Kochver- 
fahren, welches selbstredend auch auf Typhus- und anderen Aus- 
leerungen,sowie tuberkulose Sputa Anwendung findet, alle Mikroben 
sicher vernichtet. 

Ausserdem muss hier ein kleiner Desinfektionsapparat, bestehend 
in einem R. Koch'schen Topf, oder ein ahnliches gleich zuverlassiges 
Gerath vorhanden sein, welches alle WaschestUcke und sonstigen 
Gebrauchsgegenstande, die der Kranke besudelt oder benutzt hat, 
sei es ohne oder in Desinfektions-Flussigkeit, aufnimmt 

Unsaubere Leib- wie Bettwasche bringt man am einfachsten und 
besten in einen starken leinenen Beutel, welcher mit Desinfektions- 
fliissigkeit oder auch nur mit Wasser angefeuchtet ist, um jede 
Uebertragung der Krankheitsstoffe zu verhiiten, befordert den 
gefUllten Beutel sofort in die Waschkiiche und in den Waschkessel 
mit siedendem Wasser, in welchem Beutel und Inhalt mindestens 30 
Minuten gekocht werden. Auch hier muss der Grundsatz festge- 



wmiMmmmmmm^msv9ammsmammmmmam9Biam!fm 



1 54 PISTOR. 

halten werden: Peinlichste Reinlichkeit und Entfernung aller 
Schadlichkeiten sind iiberall und jeder Zeit die vorziiglichsten 
Desinfektionsmittel. 

Die Einrichtung von Fallrohren, welche innen mit Zinkbiech, 
Glas oder sonstigem glatten Material ausgefUttert und dazu bestimmt 
sind, aus den Krankenraumen besudelte Wasche und Verbandstucke 
in untere Sammelraume zu fiihren kann ich fiir zweckmassig nicht 
halten. Selbst bei grosser Reinlichkeit, die zur Zeit umfangreicher 
Epidemien nicht immer aufrecht erhalten werden kann, ist hier die 
Gefahr einer Festsetzung von Keimen sowohl im Schlot wie nament- 
lich im Sammelraum nicht ausgeschlossen, und dam it die Mbglich- 
keit weiterer Verbreitung gegeben, wohingegen der Transport in 
feuchten Beuteln eine Weiterschleppung der Keime vollstandig ver- 
hindert, nebenbei sehr viel weniger kostspielig ist, wie jene Einrich- 
tungen, welche leider auch in neuen Sonder-Krankenhausern sich 
hin und wieder noch finden. 

Bei der zweigeschossigen Baracke ist die Decke des unteren 
Raumes so fest herzustellen, dass Infektionsstoffe in den oberen 
Raum nicht gelangen konnen; aus demselben Grunde ist die in den 
Oberstock fiihrende Treppe unmittelbar am Eingang des Gebaudes 
in einem besonderen Treppenhause anzuordnen. Ist die ganze 
Baracke nur fiir eine Infektionskrankheit bestimmt, so sind diese ' 
Vorsichtsmassregeln nicht absolut nothwendig; da aber iiberall 
Verhaltnisse einlreten konnen, welche zur Belegung beider Geschosse 
mit verschiedenen Kranken zwingen, so wird man gut thun, demge- 
mass jede zweigeschossige Baracke zu bauen. Auch aus diesem 
Grunde empfiehlt es sich nicht, zweigeschossige Baracken und feste 
Pavilions mit mehreren Geschossen fiir die Unterbringung ansteck- 
ender Kranken einzurichten. Bei Pavilions wird man darauf sehen 
miissen, dass niemals ein Mittelkorridor angeordnet wird, oder todte 
Ecken entstehen, dass vielmehr nur Seitenkorridore mit reichlicher 
Liiftung angelegt werden. 

Erholungs- oder Tage-Rdume, 

Jeder Einzelbau, sei es nun Baracke mit einem oderzwei Geschos- 
sen oder Pavilion, wenn solcher beliebt wird, muss in jedem Geschoss 
einen Erholungssaal fiir Genesende erhalten, so dass diejenigen, 
welche nicht mehr an das Bett gebunden sind, sich frei bewegen 
konnen, ohne die noch bettlagerigen Kranken zu storen ; in diesem 
Raume ist auch fiir Unterhaltung durch angemessene Lektiire und 



ABSONDERUNGSRAUME UND SONDERKRANKENHaUSER. 1 55 

harmlose Spiele zu sorgen. Ebenso ist fiir jedes Stockwerk oder 
fiir jede Krankenabtheilung auf der Sonnenseite eine Veranda anzu- 
ordnen, damit die Kranken, welche den etwa vorhandenen Garten 
noch nicht betreten konnen, oder falls ein solcher mangelt, doch die 
so nothige Gelegenheit des Aufenthalts in frischer Luft haben. Dass 
ein Garten bei Sonderkrankenhausern neben einer derartigen Ein- 
richtung ein besonderer Vorzug ist, liegt auf der Hand. 

Heizung. 

Fiir jedes Gebaude eines Isolirspitals ist eine besondere Heizvor- 
richtung anzulegen, damit nicht durch die Heizkanale Fortfiihrung 
von Mikroben stattfinden kann. Urn diese Forderung zu erfuUen, 
sind die Baracken des Berliner Institutes fiir Infektionskrankheiten 
mit Kauffer'schen Ventilationsmantelofen versehen, welche beiguter 
Beheizung der Krankenraume in Verbindung mit den aus Gips- 
dielen hergestellten Luftschloten zum Abfiihren der verdorbenen 
Luft, wie schon bemerkt, einen sehr giinstigen Luftwechsel bewirkt 
haben. 

Auch andere Mantelofen gute Kachelofen in Verbindung mit 
Kaminen finden zweckmassige Verwendung, wenn nicht reichliche 
Mittel zur Verfiigung stehen und bei Isolirraumen an offentlichen 
Krankenhausern, von welchen sogleich die Rede sein wird. 

DesinfektionS'Ansialt^ Leichen- und Sektionshaus, 

Weit und zwar nicht unter 40 Metern entfernt von der Gesammt- 
anlage sollen die Desinfektionsanstalt und das Leichenhaus mit 
dem Sektionszimmer in iiblicher Weise angelegt sein. 

Eine Desinfektionsanstalt fiir ein Sonderkrankenhaus ist derartig 
einzurichten, dass diejenigen, welche mit den infizirten Gegenstanden 
zu schaffen haben, auch in der Lage sind, sich selbst hinlerher durch 
ein Bad reinigen zu konnen. In den Fever-Hospitals verschiedener 
englischer Stadte, so in Glasgow, Leicester, Liverpool, Leeds, Lon- 
don, habe ich 1891 eine meines Erachtens sehr zweckmassige Ein- 
richtung gefunden. Der Desinfektionsapparat ist, wie in anderen 
L'andern, in einem besonderen Gebaude aufgestellt, welches in einem 
Vorraum der einen Seite die infizirten Gegenst'ande aufnimmt; 
dieser Raum ist nur fiir die Bediensteten der Anstalt und Diejenigen 
zugangig, welche kranke Angehorige zum Krankenhause oder infi- 
zirte Gegenst'ande gebracht haben. Von hier gelangt man durch 
einen Gang in eine durch eine feste Mauer vollstandig getrennte, neben 



156 PISTOR. 

dem Aufnahmraum f iir die desinfizirten Eflfekten belegene Einrich- 
tung zum Baden. Nachdem die begleitenden Angehorigen oder die 
Ueberbringer von infizirten EfTekten ihre eigenen Kleidungsstucke 
abgelegt haben, treten sie durch diesen Gang in das Bad, reinigensich 
sorgfaltigst, warten noch einige Zeit in dem warm gehaltenen Raume 
und nehmen dann ihre desinfizirten Kleider aus dem Apparat durch 
eine nach aussen fuhrende Thiir zuriick, durch welche die gebadeten 
Personen selbst die Anstalt verlassen. Ahnliche Einrichtungen 
finden sich jetzt auch bei vielen Desinfektionsanstalten in Deutsch- 
land, sind aber meines Erachtens uberall nothwendig wo Angehorige 
Infektionskranke oder infizirte Gebrauchsgegenstande, welche immer 
in nassen Leinensacken verpackt sein sollten zum Krankenhause 
oder zur Desinfektionsanstalt befordern. 

Als Muster eines Desinfektionsapparates diirfte die jetzige Ein- 
richtung in dem Institut fiir Infektionskrankheiten zu nennen sein, 
welche wie die von Washington und Lion in Nottingham herge- 
stellten Apparate, alien neueren Anforderungen Rechnung tragt. 
Haupterforderniss bei alien solchen Anlagen, welche durch stromen- 
den Dampf iiber 100 Grad wirken, bleibt immer, dass todte Ecken 
vollstandig vermieden und der Dampf nicht von unten, sondern von 
oben in den Apparat eintritt, wie das bei den Henneberg'schen im 
Koch'schen Institut und den von Washington und Lion konstruirten, 
in England sehr beliebten Apparaten der Fall ist. 

Verkehr mii den Kranken, 

Um den Angehorigen einen Verkehr mit den Kranken zu ermog- 
lichen sobald der Zustand derselben es erlaubt, eine Massregel, die 
wesentlich dazu beitragt, die Abneigung der Bevolkerung gegen die 
Unterbringung der Kranken in Absonderungshausern zu mildern, 
kann man verschiedene Wege einschlagen : Wenn die Kranken sich 
bereits im Rekonvaleszentenraum auf halten, konnen die Angehorigen 
sich durch ein Fenster mit ihnen unterhalten : wo ein solcher Verkehr 
nicht moglich ist oder unzulassig erscheint, wird sich eine tele- 
phonische Unterhaltung immer ohne grosse Schwierigkeit durch 
geeignete Einrichtungen herstellen lassen. 

Beforderung der Erkrankten, 

Wenn auch nicht zum Bau und zu der Einrichtung von Isolir- 
Krankenhausern gehorig, so doch ausserordentlich nothwendig fiir 
die richtige Absonderung Kranker, ist die Beforderung derselben 
von ihrer Wohnung zum Absonderungshause. Dieselbe wird am 



ABSONDERUNGSRXUME UND SONDERKRANKENHAuSER. 1 5/ 

schnellsten, sichersten, zweckmassigsten und angenehmsten fiir die 
Erkrankten erfolgen, wenn sie nicht Privatunternehmern iiberlassen 
bleibt, wie es in Berlin der Fall ist, sondern von der Verwaltung der 
Absonderungshauser ausgefiihrt wird ; eine Einrichtung, die meines 
Wissens in Amerika, insbesondere in New York, fiir alle Kranken- 
transporte schon besteht. 

Die in London seit 1867 geiibte Beforderung von an ansteckenden 
oder G^steskrankheiten Leidenden durch das Metropolitan Asylum 
Board ist vielleicht die grossartigste aller derartigen Einrichtungen 
in der Welt, namentlich seit dem noch eine Beforderung zu Wasser 
durch Indienstellung von drei besonders fiir diesen Zweck gebau- 
ten Dampfern hinzugekommen ist, welche Pockenkranke nach dem 
15 englische Meilen unterhalb London Bridge gelegenen schwim- 
menden Hospital fiir Pockenkranke iiberfUhren. Dieses aus zwei 
Schiffen bestehende schwimmende Krankenhaus ist auf 350 Betten 
berechnet und mit einem vier englische Meilen weiter unterhalb 
gelegenen Schiffsheim fiir 800 Genesende verbunden. 

Grundsatzlich sollten alle derartigen Kranken durch Fahrgelegen- 
heiten, welche von der Krankenhaus -Verwaltung geleitet wird, 
dorthin befordert werden ; wo dies nicht zu ermoglichen ist, diirfle 
die Beforderung stets seitens der Gemeinden zu iibernehmen, oder 
mit den Einrichtungen einer gut geleiteten Feuerwehr zu verbinden 
sein. Die Wehrmanner sind durch ihren ganzen Beruf mit derarti- 
gen Nothlagen vertraut, haben in Deutschland vielfach, besonders in 
Berlin, als Samariter nach Esmarch'schen Grundsatzen ihre Ausbil- 
dung erhalten und wissen daher auch mit schwer Erkrankten viel 
besser umzugehen, als mancher Krankenfleger oder gar ein gewohn- 
licher Arbeiter bei der von Privatpersonen geleiteten Krankenbe- 
forderung. Finanziell aber wird jene Verbindung zwischen Feuer- 
wehr und Krankentransportwesen fiir die Gemeinden nicht unvor- 

theilhaft sein. 

Absonderungsrdume. 

Wenden wir uns nun von der vollkommeneren Einrichtung der 
Sonder-Hospitaler zur Unterbringung von an ansteckenden Krank- 
heiten Leidender zu den in kleineren Gemeindewesen erforderlichen 
Einrichtungen, so muss auch in Stadten unter 5000 Einwohnern 
entweder durch besondere Raume im allgemeinen Krankenhause 
selbst, oder aber in der Nahe desselben durch eine Baracke von 
geeigneter Konstruktion, sei es in Holz-,seiesin Steinbau, Eisenbau 
und so weiter fiir die Absonderung solcher Kranken jeder Zeit die 
erforderliche Gelegenheit geboten sein. Man kann nicht fordern, 



158 PISTOR. 

dass in solchen Ortschaften fiir jede ansteckende Krankheit ein 
besonderer Raum zur Verfiigung steht, muss sich vielmehr daran 
geniigen lassen, dass fiir gewohnliche Zeiten iiberhauptnur ein oder 
mehrere Raume fiir solche Zwecke vorhanden sind. 

Absonderungsraume fiir ansteckende Kranke in oder bei allge- 
meinen Krankenhausern miissen von alien iibrigen Krankenzimmem 
nebst Nebengelass nicht allein getrennt sondern auch abgeschlossen, 
das heisst, so belegen sein, dass sie einen eigenen Zugang haj^en und 
weder durch Thiiren noch durch Gange mit den fiir die iibrigen 
Kranken bestimmten Raumen und Nebenraumen in Verbindung 
stehen. Baulich sind solche Absonderungsraume nach ganz densel- 
ben Grundsatzen herzustellen, wie die Raume in den festen Baracken. 
Stets wird eine besondere Bade- wie Aborteinrichtung, ein eigenes 
Warterzimmer, gesonderte Heiz- und Liiftungseinrichtung vorhanden 
sein, auch dafiir gesorgt werden miissen, dass eine Kochvorrichtung 
fiir gef ahrliche F'akalien fiir den Bedarfsfall schnell angelegt werden 
kann. Der Desinfektionsapparat des allgemeinen Krankenhauses 
kann bei gehoriger Sorgsamkeit stetz mitbenutzt werden. Auch 
erscheint es nicht bedenklich, die Wasche aus den Absonderungs- 
raumen, nachdem dieselbe in nasse Beutel von starker Leinewand 
gehorig verpackt ist, in das allgemeine Waschhaus der Kranken- 
anstalt zu befordern, unter der Bedingung, dass der gefiillte 
Waschebeutel sofort in einen Kessel mit siedendem Wasser geworfen 
und darin mit seinem Inhalt 30 Minuten gekocht wird. Bei sarg- 
samer Beobachtung solcher Vorsichtsmassregeln ist meines Erach- 
tens jede Uebertragung von Krankheitskeimen aus den Absonde- 
rungsraumen fast ausgeschlossen. 

In epidemiefreien Zeiten, wie sie in kleineren Gemeindewesen auch 
beziiglich Scharlach, Diphtheric, Darm-Typhus oft langere Zeit 
eintreten, konnen jene Sonderraume nach sorgfiiltiger Reinigung 
mit Wasser und Seife, Desinfektion der Gebrauchsgegenstande und, 
mindestens 14-tagiger Durchliiftung zur Sommerzeit, anderweit 
benutzt werden. 

Bewegliche Baracken, 

Wo auch solche Sonderr'aume fehlen, oder bei Verbreitung an- 
steckender Krankheiten zur Aufnahme der Erkrankten nicht aus- 
reichen, da bleibt als sehr gutes Auskunftsmittel die bewegliche 
Baracke, welche ihre vollkommenste Form in der Docker'schen 
Konstruktion erhalten, heizbar ist und sich iiberall auch in ungiin- 
stigen klimatischen Zeiten bewahrt hat. Ihre Konstruktion als 



ABSONDERUNGSRAUME UND SONDERKRANKENHAUSER. 159 

bekannt voraussetzend, beschranke \ch mich hier darauf hinzuwei- 
sen, dass in neuester Zeit ahnliche Einrichtungen mehrfach herge- 
stellt worden sind, welche sich im Wesentlichen von der Docker'schen 
Baracke wenig unterscheiden, so auch eine von Selberg & Schluter 
neuerdings hier aufgestellten Baracke, deren wesentlicher Unter- 
schied von der Docker'schen in dem zu den Wanden benutzten 
Material liegt; die Wande bestehen aus zwei Linoleumplatten, 
zwischen welche Drahtgaze gelegt ist ; durch maschinellen Druck 
sind beide Flatten mit dem Drahtnetz unzertrennlich verbunden. 
Derartig hergestellte Flatten werden auf Holzwerk innen und aussen 
aufgenagelt und auch zur Dachkonstruktion verwendet. Diese Art 
der Dach- und Wandbekleidung soil sich fiir Wohnhauser in den 
Tropen bewahrt haben. 

Dass die aus solchen Sonderraumen, Einzelbaracken, kommenden 
infizirten Gebrauchsgegenstande sofort der Desinfektion sich zu 
unterwerfen sind, versteht sich von selbst. Es muss daher eine 
wirksame Desinfektions-Einrichtung fiir stromenden Wasserdampf, 
welcher Art sie auch sei zur Verfiigung stehen ; eine solche ist aber 
auch leicht zu beschaffen in Gestalt eines gehorig grossen Blech- 
topfes mit Einsatz, wie solchen Merke in der Berliner klinischen 
Wochenschrift, Jahrgang 1892, Nro. 37, zuerst zur Desinfektion fiir 
Verbandmaterial beschrieben und abgebildet hat. Weitere von 
dem Genannten angestellte Versuche haben erwiesen, dass derselbe 
Apparat in erforderlicher Weise vergrossert zur Desinfektion fiir 
Matratzen, Bet ten, Decken und andere Gebrauchsgegenstande eben- 
falls brauchbar ist. 

Einrichiung der Krankenr'dume, 

Betreffs der Einrichtung der Raume empfiehlt es sich, die Lager- 
statten aus Eisen moglichst einfach und so bequem wie moglich fiir 
die Kranken herzustellen. Ob man zu dem Zweck Drahtspiralen in 
Mannesmannrohren mit aufgelegter Decke oder aufgelegtem Bett- 
tuch verwendet, ob man auf Spiralfedern, wie vielfach in England, 
Haferstrohsacke legt, deren Inhalt dann verbrannt, deren Bekleidung 
desinfizirt wird, das bleibe dahingestellt. Nur das wird sich em- 
pfehlen, Matratzen und Decken nach Moglichkeit von der Benutzung 
durch ansteckende Kranke auszuschliessen, um eine Desinfektion 
dieser Stiicke zu vermeiden, die immerhin schwieriger ist, als die 
Reinigung waschbarer Gegenstande oder wollener Decken. Wo 
indessen derartige Einrichtungen nicht moglich sind, da nimmt man 
zur einfachen Matratze und zum Bett wieder seine Zuflucht; nur 



l60 PISTOR. 

muss auf die Desinfektion durch stromenden Wasserdampf die 
grosste Sorgfalt verwendet werden. 

Beleuchtung. 

^tan sorge f iir eine gute Beleuchtung bei Tage durch reichliche 
Fensterflache, und sperre blendendes Sonnenlicht durch entsprech- 
ende Vorrichtungen, seien es nun leinerne Vorhange von aussen, 
seien es Holzvorhange, oder verschiebbare Laden, endlich Sonnen- 
segel und so weiter, und bei Abend wo es angangig ist, durch gut 
abgeblendetes elektrisches Gliihlicht, oder auch durch entsprechend 
gemildertes Bogenlampenlicht. Wo elektrische Beleuchtung nicht 
zu erlangen ist, tritt Gaslicht ein, und wo auch dieses mangelt, wird 
man sich mit Petroleumlicht begniigen miissen, in beiden letzteren 
Fallen aber ganz besonders sorgf altig fur Regelung der Temperatur 
und Abzug der Verbrennungsgase Sorge tragen. 

Aussiaitung der Rdume. 

Sammtliche R'aume fiir die Aufnahme ansteckender Kranke sind 
so einfach wie moglich — in Eisengerathen mit Glas oder Porzellan, 
Marmorplatten und so weiter herzurichten ; alle iiberfliissigen Ge- 
rathe, Mobel, namentlich staubfangende Dekorationen, wie Vorhange 
zu vermeiden; sie werden nur Ablagerungsstatten fiir Infektions- 
keime. 

Dagegen empfiehlt sich nach englischer Sitte die Ausschmiickung 
der Raume durch bluhende Gewachse, welche aber keinen starken 
Geruch verbreiten diirfen ; durch solche Pflanzen werden die 
Krankenraume behaglich und freundlich gemacht. 

Wirthschaftsrdume, Wohnungenfur Aerzte und Pflege- Personal. 

Zum Schluss sei noch ein Wort iiber Wirthschaftsraume, Aertze, 
und Pflegepersonal hinzugefiigt. S'ammtliche Raume fiir Speisen 
und Getranke, wie deren Vorrathe, insbesondere der Speisen, sind 
isolirt von den Krankenraumen anzuordnen. Auch die Wasch- 
kiiche ist wie in grossen Krankenhausern von den Krankenraumen 
abzusondern, kann aber neben der Speisekiiche, nur ganz gelrennt 
von derselben, liegen. 

Wo nur Sonderraume oder kleine Baracken fiir derartige Kranke 
bestehen, wird die Bespeisung derselben besondere Aufmerksam- 
keit erheischen, um Uebertragung der Krankheitskeime zu verhiiten, 
es wird Sache der Verwaltung sein, bestimmte Personen allein 



ABSONDERUNGSRAUME UND SONDERKRANKENHAUSER. l6l 

fiir diesen Dienst zu verwenden. Dieses Pflege- und Dienstpersonal 
ist anzuweisen und erforderlichen Falles mit Strenge anzuhalten, 
jeden Verkehr mit dem iibrigen Personal, den anderweitigen 
Kranken und der Aussenwelt bis zum Erloschen der Epidemie oder 
zur Ablosung des Dienstes zu vermeiden und vor Aufnahme einer 
anderweiten Thatigkeit sich durch ein warmes Bad mit Seife. bei 
welchem die Reinigung des Haupt- und Barthaares sehr griindlich 
vorzunehmen ist, und Wechsel von Kleidung und Wasche sorgf al- 
tigst zu desinfiziren. 

Am meisten empfiehlt es sich, die Speisen, durch die Bedienung 
nur an die Krankenzimmer zu befordern und einem in der 
Genesung befindlichen Kranken wenn moglich die Vertheilung zu 
iiberweisen. 

Das Pflegepersonal fiir solche Kranke ist unter den geschilderten 
Umstanden streng von dem Pflegepersonal fiir die iibrigen Kranken 
abzusondern. 

Der behandelnde Arzt soil, falls er gleichzeitig alle Insassen des 
Krankenhauses behandelt, die abgesonderten Kranken stets zuletzt 
besuchen und sich selbst dann einer griindlichen Reinigung unter- 
werfen, um die Ansteckungsstoffe nicht zu verschleppen ; auf solche 
Weise ist es moglich, selbst die leicht iibertragbaren Krankheiten 
dieser Art gleichzeitig mit anderen Erkrankungen zu behandeln und 
zu verpflegen, ohne die Mitmenschen durch Uebertragung des 
Krankheitsstoffes in Gefahr zu bringen. 

Erste Bedingung bleibt fiir alle solche Verhaltnisse, dass Aerzte 
wie Pfleger und Bedienung sich der peinlichsten Sauberkeit in der 
Kleidung und am Korper befleissigen. Es wird daher fiir alles 
iirztliche, wie fiir Pflege- und Verwaltungspersonal Pflicht sein, tag- 
lich Bader zu nehmen. Die dazu erforderlichen Vorrichtungen 
miissen fest oder beweglich iiberall vorhanden sein oder beschaflt 
werden. Dass fiir Isolir- Hospitaler, welche ein besonderes Ver- 
waltungsgebaude und besondere Gebaude fiir das arzdiche und 
Pflegepersonal ha ben, stets derartige Vorrichtungen von Haus aus 
angelegt werden, sei hier noch erwahnt. 

Bakteriologisches Laboratorium . 

Den Arzten an Sonder-Krankenhausern oder bei Absonderungs- 
Krankenriiumen muss die Moglichkeit gewahrt werden, den Krank- 
heitszustand der ihnen zur Behandlung iiberwiesenen Kranken auch 
mit alien zu Gebote stehenden Mitteln der Wissenschaft zu unter- 



l62 HERBERT AND HOGG. 

suchen, festzustellen und den Verlauf der Krankheit zu verfolgen. 
Fiir Sonder-Hospitalern ist daher die Errichtung eines bakteriolo- 
gischen Laboratoriums eine unabweisbare Nothwendigkeit. 

Schliesslich sei noch erwahnt, dass fiir grossere Anlagen der Art 
besondere Gebaude, .welche moglichst entfernt von den iibrigen 
derartigen Einrichtungen gelegen sind,furPocken- und Fleckfieber- 
kranke, zu errichten sind ; in England hat man, wie bekannt, fiir 
Pocken stets besonders eingerichtete und abseits der iibrigen Fieber- 
hospitaler gelegene Pockenhauser. Wo es die Verhaltnisse gestatten, 
wiirde, wie bei London, nach dem Muster des dortigen Schiffs-Hos- 
pitals fiir Pockenkranke derartige schwimmende Krankenhauser 
sich am meisten empfehlen. Wenn in jenen Ortschaften und Gegen- 
den, wo die obenerwahnten Krankheiten haufiger auftreten, entfernt 
von den iibrigen Geb'auden der Anlage, besondere Pocken- und 
Fleckfieberhauser errichtet und eingerichtet werden, so diirfte dem 
Bediirfniss geniigt sein. 

Nur in allgemeinen Umrissen war es mir moglich, die mir gestellte 
Aufgabe zu behandeln ; es wiirde mir eine besondere Freude sein, 
wenn es mir gelungen sein sollte, in diesen kurzen Satzen auch nur 
einen Ueberblick iiber die Anforderungen zu geben, welche die 
offentliche Gesundheitspflege an Isolir-Krankenh'auser und Isolir- 
raume fiir ansteckende Krankheiten stellen muss. 



ISOLATION WARDS AND HOSPITAL FOR CONTA- 

GIOUS DISEASES IN PARIS. 

Dr. Alan Herbert, D. M., and Dr. W. Douglas Hogg, D. M., 

Paris. 

We propose in this article to describe briefly the means of hospital 
isolation as adopted by the "Assistance Publique" in Paris, a com- 
mittee controlling all the hospitals in the capital of France.* 

It is not our intention, however, in this article, to attempt any 
criticism upon the system of the Paris hospitals. Any discussion 
bearing upon such a point would be out of place here. At the same 
time, while limiting this article to a mere summary, our final aim will 
be to submit to the Section conclusions as to the means to be 

* For a more detailed account of the organization of the committee see 
our paper entitled ** Paris Free and Paying Hospitals," presented to the 
Congress. 



ISOLATION WARDS AND HOSPITAL IN PARIS. 1 63 

employed in all large centers, with a view to prevent contagion in 
hospitals during the treatment of patients affected with such diseases. 

The question of hospital accommodation for such patients has 
for some time occupied the serious attention of the governing bodies 
of the "Assistance Publique" in France. 

The interest bestowed of late years on State medicine, and the 
rapid progress made in that branch of medical science, has induced 
them, like others, to seek for improved means of treatment in such 
cases, both for the patients themselves and the surrounding popu- 
lation. 

With this end in view the administration of the "Assistance Pub- 
lique," the " Conseil Municipal " and the French government have 
considered it a duty to obtain every possible information on the 
subject. 

Without giving a detailed account of the works which have treated 
of this subject, we may, perhaps, be permitted to recall to memory 
that in the years 1884 and 1885,'*' when smallpox and scarlet fever 
were raging in London and other large English towns, the Minister 
of the Interior entrusted one of us with a special mission to England, 
to study the prophylactic measures then in force in that country. 

In 1889! the same n>inisterial department entrusted him with the 
mission of continuing these investigations, and of completing them 
by means of documents collected at the time of the Paris Exhibition. 

In Paris considerable efforts have been expended in order to 
diminish the dangers resulting from the treatment, in the same hos- 
pital, of ordinary patients and those suffering from infectious dis- 
eases. Since 1882 the principle of isolation has been adopted. 

In this year a special building was constructed for the treatment 
of diphtheria. Since then new difficulties have arisen, and it would 
be useless to-day to hide the fact that there still remains much to 
be done to prevent the spread of disease in hospitals. In order 
to prevent this propagation of infection in any town it is not suffi- 
cient to place the affected person in a hospital, but it is also neces- 
sary to take measures to prevent that person becoming a source of 
infection to the hospital itself into which he has been admitted. 

The following statistics, for which we are indebted to the kindness 

^Isolation Hospitals in England. One vol. in Svo of 250 pages, with 40 
engravings and drawings. (Work recompensed by the Institute of France.) 
Paris, 1886. J. B. Bailliire, Editor. 

t New Researches on the Isolation of Contagious Diseases, One vol. in Svo.* 
Paris, 1890. J. B. Bailliire, Editor. 



164 HERBERT AND HOGG. 

of our excellent colleague and friend. Doctor J. Bertillon, chef du 
bureau de la Statistique de la viUe de Paris, shows the number ol 
cases in which contagious diseases have arisen in the interior of the 
Paris hospitals during the last ten years. 









Siatisitci 














S-.S;:-.-...::;;;::.:::::: 






4*i 


iB«7. 

MB 


331 


.SS9. 




,B9,. 
IBS 




T0..I. 








.6; 










.0. 


.,. 


3je 


S« 


4« 


«. 


6.8 


3i6 


*8, 






'" 



It will thus be seen that during these (en years 3747 persons have 
been affected by contagious diseases which they would have escaped 
had they not entered the hospitals. It is needless for us to remark 
that this number would have been much greater if the statistics had 
included the cases of measles and erysipelas. 

Before, however, considering the resources which the Paris hos- 
pitals possess for the isolation of contagious patients, it will be well 
to consider what necessity exists for such isolation. We may judge 
of this by the figures representing the number of patients affected 
with contagious and infectious diseases which took place during the 
year 1S90. 





PAT.IHT5 D1SCMA1.U.O. 


,.„.c„„. 




D,.,.S«. 


Adulu. 


Childia. 


Adulu. 


Chnd«. 


Tout. 




M„, 


Women. 


Boy.. 


G.rl.. 


Mob. 


Women. 


Boy. 

1 
1 


Cirli. 

'i 




Typhoid 

aas-::::::.::;::;:;: 




«IO 

i 

■■■» 




1 

33! 

43 




-a 


Scvltcrmr. 

WhaopiDi-eiivib 

»i^'Wt(™.p) 


?=yri-.;^::::.-:::.::: 


.J.79B 


GcneillToUl 



If from these numbers we take only those which apply to measles, 
smallpox, scarlet fever, whooping-cough, diphtheria and cholera, we 
find that in 1890,^699 infectious cases were treated in the hospitals 
of Paris. ~^' 



ISOLATION WARDS AND HOSPITAL IN PARIS. 1 65 

We will now examine the facilities which the city authorities have 
at their disposal to meet these cases. 

According to a statement with which Doctor Peyron, director of 
the committee of the "Assistance Publique," has kindly furnished us, 
it appears that six hospitals are provided with the following means 
of isolation : * 

The Aiibervilliers Hospital possesses separate buildings for small- 
pox, measles, scarlet fever, erysipelas, diphtheria, and doubtful cases; 
in all, 184 beds. 

The Hospital Trousseau, Isolation wards are established for 
children with diphtheria, measles, and scarlet fever ( 181 beds). 

Hospital '^ des En/ants malades'^ (Enfant J6sus), which is^ hos- 
pital for children, receives diphtheria and scarlet fever patients, 
5 2 bedsi 

In addition to these the following hospitals are provided with 
isolation rooms: Lariboisi^re, 7 beds; La Ptiiiy 5 beds; La 
Chariti, 3 beds. i^ 

All these taken together make a total of 33 2 beds^ 

We will now consider each of these establishments separately. 

The Atibervilliers Hospital. 

At the time of the cholera epidemic in 1884 the administration 
constructed at Aubervilliers. near the gates of Paris, small wooden 
buildings for the isolation of cholera patients. These were intended 
to be only temporary buildings, as the ground does not belong to 
the city of Paris, but to the State ; being situated on the military 
2one surrounding the town, on which the construction of buildings 
is forbidden. 

These buildings, however, proved of so much service that they 
were maintained, and in June, 1887, were employed for the treat- 
ment of smallpox patients. 

For some months past patients from the various isolation wards of 
the different hospitals have been transferred to this establishment. 

It is composed of small buildings, entirely separate one from the 
other, and containing altogether 184 beds. Two of these buildings 
are reserved for the administration and the general service; the 
others, for the treatment of the following contagious diseases: 
smallpox, measles, scarlet fever, erysipelas, diphtheria, and lastly, 

• Up to the present time (February 1893) the Hospital St. Antoine possessed 
an isolation ward, which has just been suppressed. 



l66 HERBERT AND HOGG. 

doubtful cases. Two other small buildings, quite separate, contain, 
one, an amphitheater, the other, a compressed steam disinfecting 
apparatus and a sulphur-room. 

Each building is provided with a bath-room, water-closet, store- 
room, and attendants' dormitory. The attendants are strictly for- 
bidden to communicate with the other buildings. 

All the buildings are in direct telephonic communication with the 
central administration. 

The male attendants wear their beard and hair very short, are 
expected to wash their hands frequently in a solution of corrosive 
sublimate, to carefully brush their nails, and take at least one bath 
a week. They wear a smock-frock, a vest, and an india-rubber cov- 
ering over their shoes. 

Any person before entering the wards must put on a long, closely 
buttoned frock. When he leaves the ward this garment is depos- 
ited in a special room, from which the visitor is conducted to a 
disinfecting room. 

In the case of any outside workman being required for work 
within the establishment, he must be able to show that he has been 
recently vaccinated. 

On the arrival of a patient his clothes are disinfected by the steam 
process, his shoes and hat by the sulphur process. Their corres- 
pondence is also subjected to the sulphur process before being posted^ 

No visits are allowed. 

Thanks to these precautions, no case of contagion within the 
establishment has arisen since they were instituted. 

The Hospital Trousseau, 

This hospital, situated within Paris, 89 rue de Charenton, contains 
558 beds. It is for children only, receiving both medical and surgical 
cases. 

The following facts apply only to contagious cases, for which 154 
beds are set apart. 

The service comprises : i. Four isolation pavilions, reserved for 
the treatment of diphtheria, measles, scarlet fever and doubtful 
cases. 2. A series of wards for cases of whooping-cough. 

Each service possesses a staff of nurses, entirely separate from the 
other attendants of the hospital. They have their own dormitory 
and dining-room. 

As regards the medical service, it is performed alternately, every 
two months, by the different physicians attached to the hospital. 



ISOLATION WARDS AND HOSPITAL IN PARIS. 167 

Details of each Service. 

a. Diphtheria. (^Pavilion Bretanneau), 36 beds. 
Attendants : i lady superintendent. 

1 night assistant 

3 day nurses. 

2 night nurses. 

I male attendant. 

b. Measles. {Pavilion d^Aligre), 53 beds. 

Attendants: i assistant superintendent. 

I day under-assistant. 
I night ** 

4 day nurses. 

3 night nurses. 

I male attendant. 

c. Scarlet fever. {Pavilion Davenne), 24 beds. 

Attendants: i night assistant. 

1 day " 

2 day nurses. 

2 night nurses. 
I male attendant. 

d. Doubtful cases. {Patients under observation^^ 16 beds. (This 
service was only opened on the 23d of November, 1892.) 

Attendants : i day superintendent. 

1 night assistant. 

2 day nurses. 

2 night " 

I male attendant. 

e. Whooping-cough. No. beds, boys, 1 1 

girls, 
Attendants: i day assistant. 

I night ** 

3 day nurses. 
3 nig^t " 

Number of cases during the year 1892: 



;irls, 14 J 



Diphtheria. 


Mea&les. 


Scarlet fever. 


Doubtful 
cases. 


Whooping- 
cough. 


Admitted, 1089 


586 


248 


51 


216 


Discharged, 510 


422 


214 


44 


156 


Fatal cases, 563 


153 


25 


3 


46 



l68 HERBERT AND HOGG. 

The Hospital of the *^Enfants malades'' (^V Enfant fisus). 

This hospital, which contains 629 be^ is situated in Paris (rue de 
Sevres), in a very populous district. It receives children from one 
to fifteen years of age, and possesses both a medical and surgical 
staff. 

The isolation accommodation contains 87 beds, for the following 
complaints : diphtheria, measles and scarlet fever. 

An isolation pavilion, constructed in the year 1882, is especially 
reserved for the treatment of diphtheria. 

Two separate wards on the second floor are reserved for measles 
and scarlet fever patients respectively. 

There is, however, under consideration a scheme which will shortly 
be put into execution, for the construction of entirely separate 
buildings for scarlet fever, measles and doubtful cases. 

At the present moment the diphtheria ward contains 28 beds, the 
measles ward 25 beds, the scarlet fever ward 24 beds. 

The nursing -staff" is divided as follows: 

Diphtheria: 

I day superintendent. 

1 night assistant. 
4 day nurses. 

2 night nurses. 

Measles: 

I assistant superintendent. 
I night assistant. 
4 day nurses. 
I night nurse. 

Scarlet fever : 

I day and i night assistant. 

3 day nurses. 
I night nurse. 

Number of cases during the years 1891, 1892 : 

r Admitted, 
Diphtheria. X Discharged, 

(. Fatal cases, 

r Admitted, 
Measles. ■< Discharged, 

(^ Fatal cases, 

f Admitted, 
Scarlet fever. \ Discharged, 

(. Fatal cases, • 



1891. 


1892. 


957 


997 


455 


522 


502 


475 


509 


589 


326 


422 


183 


167 


188 


197 


173 


178 


15 


19 



ISOLATION WARDS AND HOSPITAL IN PARIS. 169 

Cases contracted within the hospital : 

Boys. Girls. 

Diphtheria, 58 34 

Measles, 149 116 

Scarlet fever, 27 19 

• 234 169 Total, 403* 

Hospital Lariboisi^re. 

Patients affected with contagious diseases are treated at the Hos- 
pital Lariboisi^re in a small isolated building containing seven beds. 

Each patient's room opens directly on to a balcony which sur- 
rounds the building. These rooms have no direct communication 
with each other. 

Independently of the medical staff there are three persons attached 
to this building, who are obliged to take all necessary precautions 
before absenting themselves from it. They are : i assistant super- 
intendent, I male attendant, i female attendant. 

Number of cases in 1891 and 1892 : 

1891. 1893. 

Men. Women. Men. Women. 

1 

Diphtheria 3 11 3 8 

Measles 11 12 4 6 

Scarlet fever 3 5 4 * 

Smallpox .. 1 

Erysipelas 36 57 36 45 

Cholera .. 6 13 

Various cases 4 23 7 45 

Total 57 109 60 118 

ZZ166 =178 

Cases discharged 1 53 1 53 

Fatal cases 13 25 

166 178 

There remains but little to be said with regard to the other 
general hospitals, viz. "La Piti6" (716 beds) and "La Charit6 " 
(520 beds), which possess five and three isolation rooms respectively. 

* We must deduct from this number about 20 cases which, on admission, 
were placed in the general medical wards when the disease was in a state of 
incubation, but which were afterwards transferred to the isolated wards as 
soon as their contagions character became apparent. 



170 HERBERT AND HOGG. 

These rooms are only intended to meet the contingency of con- 
tagious cases arising among the patients admitted whom it has been 
impossible to transfer to one or other of the hospitals previously 
mentioned. We must mention, however, that during the last out- 
break of cholera in Paris these patients occupied at " La Piti6 '* a 
medical ward which was evacuated to accommodate them. This ward, 
which comprised a division for men and another for women, was 
situated at one end of the hospital, having a separate staircase. 

The staff attached to the cholera patients had no communication 
whatever with the other employ 6s of the building, and the precau- 
tionary measures were strictly adhered to. 

During the outbreak 69 patients were admitted. There were 31 
fatal cases. 

Conc/uston, 

With regard to the foregoing subject we desire to be permitted 
to submit to the Congress a few proposals relating to hospital pro- 
phylactic measures applicable to large towns. 

The question under consideration is the isolation of patients 
affected with contagious diseases in hospitals, and not prophylactic . 
measures in general. 

In our opinion the following are the questions which have to be 
dealt with : 

I. In what manner is it best to isolate contagious patients ? 

II. Is it sufficient to have special wards in a general hospital, or is 
a separate building necessary for each disease ? 

III. Can several of these buildings be situated in the same grounds? 

IV. Do the same rules apply to hospitals destined for the recep- 
tion of patients affected with acute diseases and to those for con- 
valescents? 

To these questions we should give the following replies : 

I. In our opinion, the treatment of cholera and smallpox patients 
requires a special hospital, situated outside the town, at a distance as 
far as possible from any habitation. 

II. Patients affected with other infectious or contagious diseases 
can be treated in separate buildings, situated in the same grounds, 
provided there be a distance of at least thirteen yards between 
them, and that each building has its own distinct and separate staff. 

III. Convalescent hospitals for patients recovering from contagi- 
ous diseases should be established outside the town, in accordance 
with the preceding rules. 



PARIS FREE AND PAYING HOSPITALS. I7I 



PARIS FREE AND PAYING HOSPITALS. 

Dr. Alan Herbert, D. M., and Dr. W. Douglas Hogg, D. M., 

Paris. 

According to French law every commune or territorial division is 
obliged to provide assistance to any of their indigent members 
requiring aid. A certain number of ''communes" have hospitals 
within their limits. The law of the 7th of August, 1851, obliges such 
communes to take charge of their sick poor. The hospitals, how- 
ever, of these communes, when called upon to do so by the Conseil 
G6n6ral of the Department, are obliged to receive patients coming 
from smaller and neighboring communes who have no hospital within 
their limits, at a fixed price. These prices are fixed by the Prefect 
of the Department. 

With a view, however, to extend medical help to the poor, belong- 
ing to no matter how small a commune, and whether it be provided 
or not with a hospital (and it must be remembered that out of 36,121 
communes only 1200 are so provided), a project of law was recently 
(5th of June, 1890) laid upon the table of the Chamber of Deputies. 

This bill, which did not become law as did that of 185 1, recognized 
the admission of foreigners into these hospitals, but it did not render 
their admission obligatory on the commune. 

It may be argued that a law rendering the admission of foreigners 
obligatory should exist only in such cases as the nation to which the 
foreigners belong gave reciprocity. 

These principles of rendering aid to the poor and indigent sick 
were for the first time legally enforced by the convention of 1793, 
which decreed " that henceforth the property of all charitable bodies 
and communities should become national property." Before 1789 
all charitable institutions were governed by bodies who had little or 
no connection one with the other ; often they were quite indepen- 
dent. All these charitable institutions were managed by the clergy, 
who distributed the funds. 

The king, it is true, had power to interfere on behalf of the 
indigent population, and this regal power was employed to insure 
the execution of decisions taken by the different councils (Councils 
of Tours, Vienna, Trent, etc.). 



^J 



172 HERBERT AND HOGG. 

As early as 793 Charlemagne decreed that certain hospitals should 
become royal establishments, and instituted rules for the proper 
treatment of the poor. 

In the thirteenth century St. Louis augmented the number of 
these hospitals, and in subsequent times these institutions continued 
steadily to increase. But great as these efforts were, it was only in 
the eighteenth century that assistance to the needy, which had till 
then been entirely voluntary, was declared to be a matter of right 
and became a matter of duty. 

The convention of 1789 makes strong declarations to this effect 
in its exposition of principles. It was about this time (1791) that a 
central and unique administration for the relief of the indigent classes 
was established in Paris. This central administration, subject to the 
higher powers of the state, has continued much the same up to the 
present date. 

A law passed on the loth of January, 1849, is still in force, and by 
it the " Assistance Publique " has the direction of hospitals and alms- 
houses, as also of all relief given at the dwellings of the poor, the 
guardianship of orphans and abandoned children, and of persons of 
unsound mind. The administration of the ''Assistance Publique '' is 
under the control of the Minister of the Interior and the Prefect of 
the Seine. The direct management is confided to a director who 
acts with a "Council of Surveillance." 

The funds of the ** Assistance Publique" are partly derived from 
property which was, as we have stated, confiscated by the conven- 
tion in 1 79 1, and also from an annual grant of about the same 
amount, voted by the Municipal Council of Paris. 

In 1890 the sum expended for the maintenance of hospitals, 
including the establishments for insane patients and abandoned chil- 
dren, amounted to 22,883,163 francs. 

In 1889 the published account states that the ''Assistance Pub- 
lique" had under its control 11,989 hospital beds and 12,370 beds in 
almshouses. There are also 330 beds for confinements, to which 88 
midwives are attached. 

The medical body attached to these hospitals consists of 88 
physicians, 40 surgeons, 9 physicians treating mental cases, 9 
accoucheurs. There are also acting under the physicians and sur- 
geons 212 internes or house-surgeons, 22 pharmaciens, with assistants 
acting under them. 

All these officers are appointed after a competitive examination. 



PARIS FREE AND PAYING HOSPITALS. 



173 



The large number of applicants renders this competitive examination 
very difficult. 

We have already stated that every commune is bound by law to 
give medical relief to its indigent sick. Paris is, of course, bound by 
the same obligation and admits the indigent sick into its hospitals 
free of all charge. This gratuitous treatment, however, extends only 
to the indigent. After admission to the hospital an inquiry is 
instituted, and if it be found that the patient is in a position to pay, 
the sum of 3 francs 30 centimes a day is required of him. The 
charge for a child is 2 francs 6 centimes only. 

As a matter of fact this sum is rarely claimed. In 1886 the total 
sum paid by patients or their families for hospital assistance was only 
2501 francs, whereas the total expended was 778,840 francs. 

It is therefore fair to consider the hospitals as being practically free. 

The following statistics will give an idea of the important work 
done by the ** Assistance Publique": 

Number of patients in the hospitals of Paris in 1889 : 





Present on 


Patients 




General Hospitals. 


January x, 1889. 


Admitted. 


Fatal Cases. 


Hotel Dieu, 


835 


9,575 


1,215 


Piti6, 


729 


10,097 


1,090 


Charit6, 


577 


7,348 


705 


St. Antoine, 


758 


11,951 


1,371 


Necker, 


486 


7.515 


839 


Cochin, 


348 


5,614 


454 


Beaujon, 


445 


8,524 


912 


Lariboisi^re, 


816 


13,285 


1,466 


Cenon, 


802 


12,620 


1,521 


La^nnec, 


627 


4,141 


580 


Bichat, 


192 


2,691 


370 


Andral, 


103 


1,382 


169 


Broussais, 


258 


1,994 


235 


Temporary hospital, 


61 


598 


55 


Total, 


7,037 


97.335 


10,982 


Hospitals for special diseases : 






St. Louis, 


781 


8,825 


345 


Midi, 


265 


4,667 


12 


Lourcine, 


173 


2,093 


25 


Accouchement, 


188 


4,843 


189 


Clinique, 


112 


2,341 


55 


Aubervilliers, 


21 


706 


63 


Total, 


i»540 


23475 


689 


General Total, 


8,577 


120,810 


11,671 



174 HERBERT AND HOGG. 



ildren : 
Children's Hospital, 


484 


9674 


1,262 


Forges, 


194 


292 


7 


Trousseau, 


382 


5^015 


1,028 


La Roche Guyon, 


88 


578 


5 


Berk-sur-Mer, 


573 


778 


41 



Total, 1,721 11,337 2,343 

Total of hospitals, 10,298 132,147 14.014 

Paying hospitals, 158 2,263 360 



10,456 134410 14374 

Summary. 

10,456 

Patients treated admitted during the year, 134,410 

Total, 144,866 

Patients discharged. 

Cured or otherwise, 119,079 

Fatal cases, 1 4*374 

Total. ^ 133.453 

Total of days spent by patients in hospitals, 3.992,548. 

The statistics just given will enable one to form an opinion as to 
the requirements existing in Paris and the various resources that 
town has at its disposal. 

Paying Hospitals, 

As we have already stated, the patients received into the hospitals 
of the "Assistance Publique " are, as a general rule, treated gratui- 
tously, and it is very rare that the small contribution of from two to 
three francs a day is required of them. 

There are, however, some exceptions, and the most important is the 
" Maison municipale de Sant6," in the rue du faubourg St. Denis, 
200, which receives none but paying patients. The prices are the 
following : 

Small apartment, 12 francs per day. Small lodgings for medical 
cases, 7, 8 and 9 francs per day ; for surgical cases, 8 and 9 francs 
per day. Rooms with 2 beds, medical cases, 7 francs per day ; 
surgical cases, 8 francs per day. Rooms with 4 beds, medical cases, 
5 to 6 francs per day ; surgical cases, 6 francs per day. In these 



HOSPITAL FOR CONTAGIOUS AND INFECTIOUS DISEASES. 1/5 

prices are included medical and surgical visits, operations, dressings, 
medicines, food, firing, linen, baths of all kinds, etc. 

The Maison de Sant6 contains 333 beds, of which 187 are for 
medical and 146 for surgical cases. 

The following are the statistics of the patients treated in 1889: 

Patients admitted Discharged 

during 1889. during 1889. Fatal cases. 

Men, 1492 1,201 230 

Women, 871 727 130 



Total, 2,363 1,928 360 

There are also paying beds at the hospital St. Louis and at the Midi. 
At St. Louis (hospital for skin diseases) there are two separate 
buildings or pavilions where the patients pay from 5 to 6 francs a 
day, according to the rooms they occupy. There are 42 beds, 29 
for men, 13 for women. At the Midi hospital (for syphilitic diseases), 
where men only are received, there are 21 beds. The price is 6 
francs a day. 

Private Institutions. 

We have only mentioned in this paper those establishments which 
are of a public nature and are connected with the ''Assistance Pub- 
lique " of the town of Paris. 

There are also many private establishments where only paying 
patients are received. 

Such establishments as receive patients of unsound mind are 
subject to regular inspection by government officials. 



HOSPITAL FOR CONTAGIOUS AND INFECTIOUS 

DISEASES. 

By M. L. Davis, M.D., Lancaster, Pa. 

The importance of isolating the sick from the well in epidemics of 
contagious and infectious diseases has been fully appreciated for 
many years. The red or yellow flag has been nailed to the door, 
hoisted over the building, or placed at the masthead of the vessel 
having cases of contagious or infectious diseases within, to warn the 



t C i— 1 ^ 



176 DAVIS. 

well of the danger of approaching. The fact that these emblems of 
danger do not kill the disease germs or prevent them from working 
their deadly havoc among the afflicted inmates has been neglected. 
Many patients with the same disease are congregated in the same 
room, or in wards constructed in such a manner that no restraint 
prevents the germs from being carried to any part of ihe^ building ; 
the result is that each person appropriates the most malignant germs 
from the others, and although the disease at first may be of a mild 
type, the virulence of the contagion will increase until malignancy 
ensues. In other words, the labors of sanitarians have been directed 
almost exclusively toward preventing the spread of disease from the 
sick to the well — no attempt being made to protect those already ill 
from receiving more of the disease germs and thereby aggravating 
each individual case. Hence we frequently see the anomaly of build- 
ing cheap, temporary wooden structures for hospital purposes, so that 
when they become saturated with poison to such an extent as to 
render them untenable, they can be burned and rebuilt at less outlay 
than a permanent building would require. This may be a very effec- 
tual method of destroying the germsof disease, but is neither rational 
nor in keeping with the present state of preventive medical science. 

The Municipal Hospital at Philadelphia is too small to accommo- 
date the cases of contagious diseases sent to it, and it is only a few 
days since we read the suggestion of some of the authorities that 
temporary wooden buildings be erected, and destroyed when no 
longer safe to be used ; this practice is, therefore, not obsolete. The 
ideal hospital for contagious and infectious diseases must meet the 
following requirements : 

1. It must completely isolate the sick from the well. 

2. It must prevent one patient from receiving and appropriating 
the malignant germs from others having the same diseases, and 
thereby preventing aggravation of the disease in both. 

3. It must destroy all the disease germs given off from the sick 
within its rooms. 

4. It must prevent the escape of any disease germs to poison earth, 
air, food and water — the media through which contagious diseases 
are known to spread. 

Description of Hospital. 

The ground-floor plan of the hospital building consists of a central 
building, with wings or wards radiating from it of any desirable number 



HOSPITAL FOR CONTAGIOUS AND INFECTIOUS DISEASES. 



177 



and length. The first floor of this central building is divided into rooms 
foroffices, dining-room, bath-rooms, kitchen, disinfecting chamber, etc 
In the corridors is an iron stairway leading to upper stories ; back of 
this stairway are situated the furnaces; one a garbage furnace, the 
other a reverberatory furnace for cremating the bodies of patients 
dying of contagious or infectious diseases. The burning gases from 
these furnaces pass under the boilers and thence into the stack, thus 
being utilized to produce steam for both heating and disinfecting 
purposes. The disinfecting chamber is situated at the side of the 
boiler and the cremating furnace ; it is made of boiler plate, and is 
provided with tight-fitting clamp doors, with rubber packing. This 
chamber is connected with the boilers and with the retort of the 
cremating furnace, so that steam, dry hot air, or sulphur fumes can 
be used at pleasure. Radiating from the central building are the 
wards for patients. Each ward has a central hallway running length- 
wise, with rooms on either side. 




Figure i shows the central building with one room completed 
and the other six wards incomplete. These may be added from time 
to time, as needed, without inteifering with the proper working of 
the plant. 

Figure z is a cross section through two rooms. Each room is 
provided with a vestibule having two doors, one opening into the 
hallway outward, and the other opening inward into the room. 
These doors are provided with a common spring, so that only one 
can be opened at a time; they are made air-tight by gum packing. 
Each vestibule is provided with a vessel containing a disinfecUnt, 
and everything taken out of the room is here disinfected before 



yf^ ■ 1 










/ 


t 

\ 

V . 






^ A 




(1 


^ 




fc 


\^- 


^^^^^^Suf 




\ 




i't 

lb 


^1^^^^^ 


■M 


■■■■- 



HOSPITAL FOR CONTAGIOUS AND INFECTIOUS DISEASES. I79 

being taken into the hall. The rooms each have one window, which 
is air-tight ; the walls are plastered with cement, to allow disinfection by 
Steam without injury. Under each hall floor is a large air-pipe running 
the entire length, and indicated by dotted lines in Figures i and 2. 
This is the ventilating pipe, and by its branches to each room and 
vestibule runs into the central building and ends in the ash-pit of the 
furnaces. The suction thus produced on this pipe by the furnaces 
and stack draws the air out of the rooms and vestibules, and with it 
all the disease germs present, which are consumed in passing through 
the fire. The heating is by steam pipes from the boilers. Each 
room is provided with a stop-cock, by opening which the room can 
be disinfected with steam and rendered pure and clean in a short 
time. Each room is provided with a metallic waste receptacle with 
tight lid; all waste is placed therein, disinfected in the vestibule, 
carried to the garbage furnace and the contents there burned. Each 
room is provided with electric call-bell and gas-light. 

All fresh air admitted to the rooms and vestibules comes through 
a trapped pipe; it is placed near the ceiling. It is packed with 
absorbent cotton saturated with any desired antiseptic. 

Figure 3 is a vertical section of garbage furnace. As will be 
seen, it consists of three chambers — the Primary Fire Chamber, 
Garbage Chamber, and Secondary Fire Chamber. The flame from 
the primary fire chamber passes through the garbage which has 
been dumped upon the grate, and dries it thoroughly, the gases 
driven ofl* passing in the form of smoke to the secondary fire chamber, 
where they are consumed, and where combustion is so complete that 
no residual odor can be detected at the outlet from the stack. 
Liquid waste drips into the evaporating pan, where it is vaporized by 
means of a pipe running from the bottom of pan to the fire in primary 
chamber, the steam thus produced passing out of jet at the end of 
the garbage chamber and assisting combustion at the most needful 
point in the secondary chamber. When the charge has been 
thoroughly desiccated the grate is lowered and the dry product is 
dumped into the fire in primary chamber, where all its organic con- 
stituents are finally consumed, being utilized as fuel to dry subse- 
quent charge. This furnace may be built to any scale to meet the 
wants required, being simple and economical in construction, easy 
of operation and giving perfectly satisfactory results. Provision is 
made in the garbage chamber for receiving the vessels containing 
excrement from the rooms, whereby, after their contents are destroyed, 
they are easily removed. 




Fig. 3. 

Figure 4 gives a cross section and longitudinal section of rever- 
beratory retort furnace for the cremation of the bodies of those who 
die from pestilential diseases. This furnace is now in use at Swin- 
burne Island Quarantine Station, New York. Municipal Hospital, 
Philadelphia, and at a majority of the crematoriums in the United 
States. The body is placed in a tight retort, which is surrounded 
by flues, through which the fire travels, heating the retort to any 
degree desired. The heat of the retort distills off the gases from the 
body; they are not burned in the retort, but pass through a pipe to 
the ash-pit, and are there delivered under the grate of the fire cham- 
ber, where final combustion is so complete that analysis by Dr. T. 
B. Baker, of Millersville State Normal School, of what escaped from 
the chimney gave the following : 



Before cremation, 


H,0. 

.0011 


CO,. 

.00080 


.000 


0. 
.0080 


CO. 
.0000 


.016 


During cremation. 


.0044 


.00091 


.012 


.0065 


.0017 


.015 



The chemist adds that " none of his tests indicated the presence 
of anything that could pollute the air." The combination of the 



l82 DAVIS. 

garbage and cremation furnaces with the antiseptic hospital, the 
author believes, covers the whole ground thoroughly and brings the 
subject abreast of modern science. 

Discussion. 

The Chairman. — The transmission of bacteria through the air in 
cases of contagious disease is rare, except in the case of measles. 
The transmission of typhoid fever is always, directly or indirectly, 
through the discharges, and if those are promptly cared for there is 
no danger in placing typhoid fever patients in wards with other 
patients, and in fact it is done every day in almost all hospitals. 
Scarlet fever is a disease that can be isolated with tolerable ease, if it 
is taken early. It may be recognized usually within 24 to 36 hours 
after the outbreak of the initial fever, and physicians usually have no 
difficulty in isolating scarlet fever cases in private houses where they 
can place the patients in a separate room on an upper floor, taking 
special care to remove from the room all things which cannot be 
treated by boiling or disinfectants. 

In diphtheria, if the discharges from the throat and nose be properly 
taken care of, there is little danger of infection. The special germs of 
diphtheria and of typhoid fever never rise into the air from moist sur- 
faces, unless carried by insects. If they are allowed to dry and form 
a crust on the edge of the vessel, or on a handkerchief, towel or sheet, 
the fragments may pass off in the shape of dust and become very 
dangerous. The ways in which such diseases as diphtheria may be 
transmitted are, as you all know, multiple. A patient has diphtheria; 
. the nurse wipes his mouth or his nose with a handkerchief, and 
leaves the room without washing her hands. She may inoculate the 
handle of the door, as she goes out, with the bacillus of diphtheria, 
and the next person who places his hand upon that door-knob may 
get the germ on his fingers and thence to his mouth. Bacteriology 
simplifies the construction of hospitals for contagious diseases 
immensely. With our present knowledge of the causes of wound 
diseases, it is the business of the surgeon to keep the hospital free 
from their germs. We do not now expect hospitals to become 
centers of wound infection ; and there is not the same danger in 
treating surgical cases now that there was fifteen or twenty years 
ago, when the immediate and special cause of these things was not 
understood. Dr. Davis proposes to filter all the air that comes into 
a ward for infectious diseases, through a layer of cotton-wool satu- 



HOSPITAL FOR CONTAGIOUS AND INFECTIOUS DISEASES. 1 83 

rated with a disinfectant. What is the danger of letting fresh air 
into a ward for infectious diseases? We should rather consider the 
subject of disinfecting the air as it goes out of the ward or hospital. 

It is above all things desirable to get the public to understand that 
there is very little danger in a hospital for diphtheria, scarlet fever, or 
measles, separated the width of an ordinary street, even, from the 
surrounding houses. If there was a hospital of that kind next door 
to my house, separated by a brick partition wall, I should not have 
the least fear of anything coming through it or of any contagion 
coming from it. The details of construction may be made very 
elaborate, as, for example, in the special isolation ward in the Johns 
Hopkins Hospital, where each room is separate, with separate air 
space. The purpose was to have the patient absolutely isolated from 
all the other patients in that building. 

Dr. J. L. NoTTER. — I fully agree with you, Mr. Chairman, in the 
remarks you have made. It is important to recognize that these 
hospitals are the centers from which disease may spread. Immense 
numbers of patients are treated in the Hospital Tents in London — 
smallpox patients — yet not a single case of infection has ever been 
traced to the proximity of those tents. 

Now, on the question of disinfection. The disinfection of the 
clothing of a patient is one of the most important points in the man- 
agement of infectious hospitals — not only the clothing which the 
patient brings in with him and his bedding, etc., but also to see that 
nothing goes out which can carry any disease germs of any sort. 
Dry heat is no use whatever. If you use heated air, the temperature 
is such that it will disintegrate the fiber of any clothing and destroy 
the material long before it will have any result in destroying the 
disease germs. The only true method seems to me to be to treat 
the clothing by atmospheric pressure. 

A Delegate. — I wish to ask what the effect would be of carrying 
patients in ambulances through the streets, to hospitals some distance 
away, in the case of infectious diseases. 

The Chairman. — If it is done with proper precautions there is 
little risk. Care must be taken not to scatter anything in the way of 
infectious dust from such a person ; but for all the diseases which 
are ordinarily sent to contagious disease hospitals no special precau- 
tions are required. In the case of cholera, care must be taken, by 
the use of either rubber sheets or absorbent goods, to prevent any 
discharges from getting into the street; and the ambulance itself 
must be thoroughly cleansed with reliable disinfectants. 



184 STEHMAN. 

DIET-KITCHENS IN HOSPITALS. 
By Dr. H. B. Stehman, 

Superintendent Presbyterian Hospital^ Chicago, 

Of all the means at the command of the physician in the treat- 
ment of disease, none stands higher than a properly selected and 
carefully prepared diet 

The materia medica furnishes us with various agents which posi- 
tively modify diseased processes by inhibiting or restraining the 
force-centers which govern circulation, and thus change physiological 
or pathological action, or excite nervous and muscular energy, but 
in doing so one only increases or diminishes the energy which has 
had its origin in potentialized food properly assimilated. 

A drug may call forth or generate action, may rally vital force to 
bridge a crisis, but any show of strength is but the manifestation and 
expression of latent force derived from and stored up from food long 
since appropriated by the organism. 

While these facts may be self evident, nevertheless they are too 
often forgotten by those who magnify the domain of drugs. More- 
over, as physiology and pathology are being better understood, 
many articles of diet have already assumed a definite place in the 
treatment of disease. 

They not only seem to have a specific action in restraining or 
increasing tissue change, but in some as yet mysterious manner man- 
ifest a selective action in the case of special diseases. They also 
affect individuals differently; for example, to some certain vegetables 
are positively harmful, producing distressing symptoms, while to 
those of a nervous temperament a juicy beef-steak is almost as stimu- 
lating as a glass of wine. 

The alert of the profession, recognizing these facts and wishing to 
utilize them, turn for help to the trained nurse. Her advent is coin- 
cident with the modern methods of medicine and surgery. 

But for the discovery and practice of asepsis in surgery and allied 
principles in medicine, her coming into the profession as principal 
assistant would have been indefinitely postponed. And thus as her 
services are being more and more appreciated from the view-point of 
the surgeon, so, as food values become better understood both in the 
selection and proper administration, her co-operation will be more 
and more sought after by the physician. 



DIET-KITCHENS IN HOSPITALS. 1 85 

To fit her for this branch of her work is the mission of the diet- 
kitchen. 

As the manual training school is the tangible expression of the 
dignity with which our modern times recognize manual labor, so the 
diet-kitchen in its design is the realistic representation of labor once 
regarded as menial but now genteel. In its relation to the hospital 
its aim is to supply better food ; in its relation to the nurse it is first 
a laboratory and secondly a dispensary. 

The diet-kitchen in the hospital, in our judgment, is not a little 
kitchen in contrast to the main kitchen. 

It is not a place where cooking is done for the mass, or where 
anything is prepared in gross, but it is a school where a nurse 
reduces her theory to practice in cooking for the individual as she 
will be expected to do when she engages in private work, and thus 
becomes efficient in every branch of her art. 

Whether a kitchen such as I have described should form a part of 
the hospital is a question that is still subjudice. 

There are many who, having given the subject much thought and 
study, and appreciating the benefits from having such an important 
adjunct in caring for the sick, are prevented from adopting it on 
account of the extra expense ; while there are others who prefer to 
travel the beaten paths of the good old ways and do not take kindly 
to any innovations. 

It thus happens that comparatively very few hospitals in this 
country have a diet-kitchen proper, and even of these few there is no 
unanimity as to the relation the kitchen should sustain to the hospital 
dietary ; the one maintains that it should be of and for the hospital, 
while the other would consider it simply as an experimental labora- 
tory whose products possessed only an incidental value. 

We believe that the former is the proper idea for hospitals in gen- 
eral, i. e,, that the diet-kitchen should be responsible for a portion of 
the food supplies ; and to make it as practical as possible for the 
nurse it should furnish only such food as with the preparation of 
which she ought naturally be familiar. That it should deal directly 
when possible with the individual, not only that it may stimulate and 
call forth the best efforts of the nurse, but in having prepared her 
food she may learn how to present it to the best advantage. 

The value of a diet-kitchen to a hospital is estimated entirely by 
the degree of responsibility it assumes in feeding the inmates. 

If it aims to care for such inmates as are upon liquid or special 



l86 STEHHAN. 

diet it relieves the general kitchen of its most burdensome task, viz., 
the details. A diet-kitchen in doing this becomes an invaluable help 
to any hospilal ; it economizes food, in that it supplies only that which 
ia needed and in such quantities as may be required. If, however, 
its aim is only to produce so-called dainties and delicacies which 
have neither sense nor nutrition, and have nothing to recommend 
them but their ability to foster and feed a fermentative dyspepsia, 
we had better confine ourselves to simpler methods, 

When the kitchen exists only for the nurse, irrespective of the 
mutual advantage it might be to both hospital and nurse, and as such 
is an ornament of the former, then it is of little or no benefit. Under 
such circumstances the hospital is the benefactor of the school to 
which the nurse belongs and is repaid only indirectly, as the service 
from experienced nurses is more intelligent, hence more efficient. 

The nurse is the one to hail the advent of diet-kitchens; to her it 
means more than any other part of her training. To know food 
values, their respective relation to health and disease, is incalculable; 
but to be able to so prepare the food that by its relish and taste it 
may not only create its own demand, but become a formidable factor 
in sustaining life and combating disease, is still a greater advantage. 
The individual who by her art can devise and suggest means by 
which the appetite may be coquetted, and distaste be changed to the 
enjoyment of food, stands in closer relation to the patient than the 
physician; for the latter may stimulate energies which are latent, 
while the former gives to the patient the very energy by which con- 
valescence is inaugurated. 

To cook efficiently and to furnish proper food is an art which is 
acquired only by practice. There are general principles which apply 
to this form of work, the same as to any other accomplishment, and 
to know these makes the nurse, at least so far, master of her profes- 
sion ; to be ignorant of them renders her liable to failure. As wrfl J 
might one expect a physician to succeed in the treatment of d 
by simple book knowledge, asanurse to cook acceptably forari 
who has had no practical apphcation of the principles which ag 
the art of cooking. 

Permanency. 

To properly manage a kitchen, whether it shall be an adjm 
the hospital or not, requires much tact. To make it what it^ 
be to the nurse requires hearty co-operation on the pan a 
cerned. 




DIET-KITCHENS IN HOSPITALS. 187 

M rule in hospitals varies. In some the nurse goes into the 
kitchen as a junior and ilience becomes a senior, and so on, she in 
turn leaching those under her; the kitchen in tlie meanwhile being 
supervised by some one especially appoinied for the purpose. 

Didactic lectures are given in classes, while the practical applica- 
tion is made only by twos and threes. 

To secure, however, that permanency which is so essential to success 
in this department, the plan which keeps a permanent tutor in con- 
stant attendance, in my judgment, secures the best results. 

Diet-kitchens are supported in three ways, by the hospitals with 
which they are connected, by the training schools, in a measure, 
whose pupils reap the advantage of the schooling, and also by private 
individuals. 

It is questionable whether any greater charity can be bestowed 
than to furnish means by which the coming generation could learn 
how to cook well. 

It is a lamentable fact that many of the pupils entering a training 
school have no more idea of cooking than they have of medicine, and 
the individual who is generous enough lo furnish the means by which 
they may not only acquire the art of making life enjoyable to the 
confirmed dyspeptic, but even enter into the secret of saving life, is 
truly a benefactor of humanity. 

It is indeed unfortunate that the introduction of the diet-kitchen 
has a financial side to it. A department so important, yet so 
neglected, necessarily comes under this same question, and judgment 
is deferred until the answer comes, Can it be afforded ? No matter 
how anxious hospital managements may be lo turn out efficient 
nurses (for they after all are their best advertisement), charitable insti- 
tutions for the gieaicr pai t have such sickly existences, and funds 
slowly, ill. It iliijy are obliged to weigh carefully every 
themselves with what are gener- 
al 'cs. 

rgument to introduce a kitchen, well 
jst every hospital in this country, pro- 
mid not add to the financial burdens 
And thus it happens thai ihey are 
i which feel the necessity of leaching 
agretd Im train. Under such circum- 
e of tlis ir, lining school, and should be 
ncr oiiiirge against the respective 



1 88 STEHMAN. 

The practical side of this question is, what to do with the food 
which the kitchen turns out. 

It would be hardly right to suggest that in the beginning possibly 
some of the articles cooked would probably not be considered very 
wholesome ; it is at least fair to presume that in the start somethings 
do not hit. 

But this is only in the start, and here is where the great advantage 
of cooking training comes in. Cooking is a science, true and exact. 
With proper conditions one can always be sure of positive results, and 
thus to produce and become familiar with the conditions, to weigh 
their importance and estimate their relation and value, make cook- 
ing an art and a science. As for the use of the kitchen product, I 
am satisfied that a kitchen, while it may be the laboratory and train- 
ing school of the pupil nurse, will produce better results if the nurse 
feels that her effort will be recognized, for there possibly can be no 
higher incentive for honest, faithful and conscientious work than to 
know that the product will be of benefit and be appreciated by some 
invalid. What is a tutor's approbation compared to a patient's 
appreciation ? What is the ability to cook food compared to the 
pleasure of having an invalid or a friend enjoy it ? I am convinced 
that, as art can be more artistic and that as skill can be more skillful, 
the consecutive classes of cookery will not only show varying degrees 
of art and skill, but that the influence of this incentive will be recog- 
nized and commented on by the patient. And so I say for the 
nurse's sake, if not for economy's sake, cook for the patient, and not 
simply for the sake of practice. 

It is not the province of this paper to discuss the general curri- 
culum laid down for nurses in the respective training schools, but it 
can safely be said that even for the good of the various hospitals the 
importance of properly selected and prepared foods is too lightly 
dwelt upon. 

Some of the branches now taught have little or no practical value, 
though they may be necessarily estimated from the standpoint of 
finish, but with nursing proper they have nothing to do. Not so with 
practical cooking. 

Cooking is not only an art, but proficiency in this respect on the 
part of the nurse will do more to ingratiate her into the heart of her 
patient than any other part of her profession. 

Nothing so buoys the spirits as good, well cooked food. A dainty 
meal will dispel the blues, soften the heart, give courage, and bring 
in a gtneraljbon esprit. 



HOSPITAL DIETARIES. 1 89 

All this is the privilege of the nurse or the school to which she 
belongs, and no words can be too strong in urging the schools to 
provide amply for teaching this branch of nursing. And I am con- 
fident that if the person in charge of the kitchen possessed and would 
cultivate the ingenuity of the French, who construct so great variety 
from so little, that the kitchen would not only be a good investment 
for the hospital, but that the trained nurse's work and skill would 
still further commend itself to the sick public. The diet-kitchen, to 
be ideal, should be a laboratory. What this is to the druggist in 
that he combines and makes new formulas, studies reaction, solu- 
bility and the various properties of drugs, so the course in the kitchen 
should embrace the combination of foods in a systematic way, so that 
in the combination and treatment of exact amounts exact results 
may obtain. 

Previous to entering the kitchen the nurse should receive instruc- 
tions in food values, its care and preservation. 

She should understand the chemical subdivision of food, and what 
changes occur as it enters the mouth and passes through the alimen- 
tary canal, and thus she will more readily arrive at the rationale 
of its administration. 

If this preliminary work is carefully done, the field of the diet- 
kitchen will gradually widen ; and if efficiency in diet-cooking rather 
than inferior branches shall become among the first requirements for 
the graduation of a nurse, the public will then more easily be con- 
vinced that the trained nurse is a professional whose skill even a 
new-born will acknowledge. 



HOSPITAL DIETARIES. 
By Miss M. A. Boland, 

The Johns Hopkins Hospital^ Baltimore, 

It is perhaps not necessary at this late day in the nineteenth cen- 
tury to offer any arguments or apologies for presenting a paper on 
the subject of food and its preparation, for we have made such strides 
in the last ten years in what may be called the study of home affairs, 
that the idea is no longer a new one, and we have already begun to 
think of system, methods, technique in the cooking of food. 



190 BOLAND. 

In a short paper of this description, however, it will be quite impos- 
sible to do more than touch upon a few salient points, to select what 
seem to be the greatest defects — for that there are defects one has 
only to look in order to see — in hospital kitchens and dietaries, 
and to suggest in a general way remedies therefor. 

With this object in view I have visited during the last three months 
twenty-five hospitals, four Young Women's Christian Associations, 
one New England Kitchen, and one school in which three hundred 
persons are furnished each day with dinner at a fair cost. The last six 
institutions are included because in hospitals the providing of what 
is known as *' ward diet," that is, the greater part of the food con- 
sumed, is neither selected nor cooked differently from what it would 
be if it were designed for those who are in a state of health. These 
institutions, excluding those not hospitals, located in six of our lead- 
ing cities — New York, Philadelphia, Boston, Washington, Brooklyn, 
and Baltimore — represent for the most part types of hospitals. Some 
are richly endowed, others are poor. Some are marked by the dis- 
tinctive religious character of the authorities, such for instance as the 
German Hospital in Philadelphia, in which the entire charge of every- 
thing except the medical work, that is, the nursing, buying and cooking 
of food, and internal management of the institution in general, is in 
the hands of the order of Deaconesses and most admirably adminis- 
tered. Others are without any special religious motive in their 
administration. Some are under political control, some are free 
from it. Some are for the rich alone who pay large prices ; others 
for the poor who pay nothing, and so on. These I have divided 
into three classes, basing the classification entirely upon the condition 
of the kitchens, utensils and workers as to cleanliness^ because it is 
the very first essential to the attainment of wholesome food. One 
may have the best of materials in proper variety and entirely fail to 
secure from them health-giving food without this element. 

Class I includes those which are good, that is, with kitchens and 
appliances, store-rooms, refrigerators, dressers, serving-rooms, dishes, 
food and food materials, positively clean and well kept. 

Class II consists of those institutions in which there is a passable 
degree of cleanliness, some care, but much indifference ; and 

Class III those which are positively bad, the neglected kitchens, 
the " submerged tenth " of kitchens, so to speak. In Class I, those 
unquestionably good, of which there are six, many excellent features 
were seen ; two have kitchens which were models of neatness, con- 



HOSPITAL DIETARIES. I9I 

taining modern appliances in excellent order, with corners, insides of 
dishes, ovens and " out-of-the-way " places as carefully kept as the 
tops of the tables and more noticeable parts of the rooms, indicating 
that cleanliness is a reality and not practiced for show. One house- 
keeper, whose refrigerator I have marked number one of the whole 
list, told me that twice each week everything was taken out and the 
woodwork thoroughly washed, scoured and aired. It contained 
distinct compartments for meats, butter and milk, vegetables, fruits, 
wines and jellies, and miscellaneous cooked food ; the different kinds 
of vegetables were kept in large sliding drawers on a level with the 
hand, as were also the fruits. The bread, which was delicious in 
flavor, was stored in ordinary flour barrels which were immaculately 
clean both inside and out and stood in a store-room of the same 
description. All food seen was most wholesome in appearance and 
appetizing. The tops of working tables were covered with sheets of 
zinc tacked on at the sides, which can be so easily made clean with 
hot water and soap, thus saving the necessity of laborious scouring. 
Granite-ware utensils were in use, and there were several large double 
boilers, with which only the thorough cooking of cereals can be easily 
and successfully done. I find on referring to the notes made after 
each visit that in all of this class of hospitals women are in charge of 
the kitchen department. 

Class II we may pass without comment further than to say that 
they were simply ordinary — not as bad as possible, but far from being 
good. Of this class there are also six out of the twenty-five, some of 
which are in the charge of men, and some in the charge of women. 

Of Class III, those which are very bad, three were filthy in the 
extreme, — drawers, cupboards and corners swarming with vermin, 
refrigerators and sinks having the appearance of never having been 
washed, food lying about in the presence of swarms of flies, and many 
other signs of the entire disregard of all rules of even a decent degree 
of cleanliness. This of the three classes is unfortunately the largest, 
thirteen out of the twenty-five composing it. Of these, in five out of 
the thirteen the buying is done by men, and of the three worst of 
this class it is noticeable that both the buying and cooking are done 
by men, — in other words, men have entire charge of the food to the 
time it is served. It is a surprise to find that of the thirty-one insti- 
tutions known about, in the three that are pre-eminently good the 
buying, cooking and entire charge of the cuisine is in the hands of 
women, while in the three as pre-eminently bad it is in the charge of 



192 BOLAND. 

men. I say it is a surprise, because the question naturally arises 
whether women in such positions would show the ability to buy to 
advantage and to provide with the same constancy that characterizes 
men; but in these days of universal educational advantages, of high- 
schools in every country town, in the present generation many women 
are well educated and possessed of discriminating minds, good judg- 
ment and that moral balance and tone which guide them to do good 
work for its own sake ; which qualities have been generally lacking 
in what may be termed the old-fashioned housekeeper, who, with no 
mental training worth mentioning, lacked the business ability to deal 
with large quantities and the power to systematize work. 

At all events these are interesting facts : the three institutions 
referred to for excellence are large institutions, two of them hospitals ; 
they have been in existence for some years, have always been in the 
entire charge of women, and are to-day models of their kind. It 
would seem that women have the instinct of attention to nicety of 
detail that men do not possess, and which in cooking is so necessary, 
as it is largely a work of minutiae. 

If we regard the twenty-five hospitals seen as typical examples of 
the hospitals of the country, we find that at leastone-half of them are 
far from being what they should be, and of the remaining half, two- 
fifths are at least capable of being much improved. 

The condition of the kitchens as to cleanliness, upon which to base 
a classification, was selected not because there were not many other 
factors upon which a classification might be made, but because the 
condition as to cleanliness is a symptom which indicates in a general 
way healthful or unhealthful food, and thought and care in cooking 
it, or the lack of it. 

The inspection of these thirty-one institutions has given tangible 
material upon which to base the conclusions which have been drawn, 
after much deliberation upon the subject and viewing the food ques- 
tion from many sides. 

The conclusions are these : that it is not lack of money, not lack 
of an abundant and varied food supply in the markets, not lack of 
necessary help, that gives to the inmates and employes of so many 
institutions a diet upon which they cannot fail in the long run to 
degenerate in health, and which for those positively ill is wholly 
inadequate to tempt the appetite, or, with appetite present, to restore 
to health. There is, it seems, enough food material, enough money 
to buy it, and hands enough to cook it. Where then does the diffi- 



HOSPITAL DIETARIES. I93 

culty lie ? Why then is the subject of food in institutions in which 
it is not wholly ignored, ever one of constant perplexity and conten- 
tion? These questions are not capable of being answered simply, of 
being solved by a single statement ; they involve too many factors 
for that; we may, however, select some of these factors and endeavor 
to deal with them. I would say that first there is a lack of affection- 
ate interest in the subject on the part of many connected with it. 
The buyer buys, the cooks cook, but no one cares whether the dishes 
made are acceptable to the eater, or whether they are eaten at all. 
There is too little loving consideration for the ultimate welfare of the 
consumer. Few have the motive of preparing "something good " for 
somebody. 

Food is too often bought by contract, by commissioners and 
others who never even see the people who eat it. The details of 
selection are frequently left to the sellers, who are often both shrewd 
and unprincipled enough to send materials that cannot be disposed 
of to the individual buyer, knowing full well that once in the institu- 
tion there they will remain, that no one will take the trouble to send 
them back, or perhaps notice the difference between the good and 
the bad. 

Usually the cook holds much the same relation to the eater that 
the buyer does, often not knowing anything whatever of those for 
whom he labors, and therefore having no incentive to please or to 
take vital interest in the work. The personal element is lacking. 

Cooks are human beings who in order to do well need instruction, 
encouragement and criticism. They should at times be told when a 
dish is good or when it is bad, and if possible why it is so; otherwise 
the best of them fall into a state of drudgery, whose round of duties 
consists in the mechanical turning out of so much bread, meat and 
vegetables with but little regard to the quality and acceptability of 
them. 

Second, there is an alarming degree of ignorance in regard to the 
necessity of cleanliness in the care and preparation of food. I have 
seen a baker smoke day after day as he molded and mixed bread, 
and in the afternoon when his work was done the same man was in 
the habit of taking a nap on the molding board, which during his 
waking moments he occupied instead of a chair. I have seen quar- 
ters of beef taken from the bottom of a none too clean cart, thrown 
upon the filthy floor of a store-room, whence they were carried to a 
block bearing all the signs upon its surface of the incipient putrefac- 



194 BOLAND. 

tion of the remains of many previous quarters of beef, chopped up in 
the presence of a swarm of flies which had been foraging during the 
morning in all sorts of decaying matter, and transported to the kettle 
without further care. I have seen large stationary soup-kettles 
washed out with the broom used for the floor. These are among the 
mildest illustrations that I could find in my long list, as the details of 
many are too unpleasant to relate. Many a woman who would be 
shocked at a speck upon the snowy whiteness of the table napery 
eats bread mixed and molded by hands whose owners know not the 
meaning of the word '* bath," who are as guileless of soap and water 
as the wandering savage ; and many a man who can give to delighted 
audiences the fascinating accounts of the life and history of the 
infinitely tiny forms of life which his microscope reveals, who can 
tell you the number of millions of bacteria that may be found in a 
gram of butter, that the dreaded typhoid-fever bacillus finds a com- 
fortable home in milk, that the germ of Asiatic cholera may live in 
varying times fi'om one hour to twenty days upon bread, roast meat, 
in water, milk, and butter, on the surfaces of fruits, on the bodies of 
flies, etc., has not yet thought of taking, the kitchen as an experi- 
mental field. This man, if he would enter the average hotel or 
hospital kitchen, might find himself in a tropical forest of micro-or- 
ganisms whose luxurious growth and transforming power might give 
the clue to many a case of sickness, degenerated health, — disease. 

Esthetically this is not pleasant ; hygienically, it is without doubt 
one of the serious factors in the food question. That fermentative 
and putrefactive changes take place with great rapidity, under favor- 
able conditions of warmth and moisture, in all kinds of both cooked 
and uncooked food, is an established principle. Of the nature of 
these changes and of the products which result from them we are not 
yet well informed, but experiments are constantly being made in this 
direction, and the day is not far distant when we shall have sufficient 
proof to speak with positiveness on more of these subjects. 

A recent work — " Lehrbuch der Intoxikationen," by Dr. Rudolph 
Robert, Stuttgart, 1893 — contains interesting matter on this point. 
According to him, sausage poisoning, which frequently occurs in 
Germany and sometimes in this country, depends for the most part 
upon a mixture of bases of which ptomatropin is the most important. 
Its formation is due to the action of a bacillus. About 40 per cent 
of those attacked die. The symptoms of the poisoning are fully 
described, and then he adds : " Wholly analogous symptoms have 



HOSPITAL DIETARIES. I95 

followed the eating offish no longer fresh, corned beef, tainted ham, 
old roast fowl (goose and duck), decomposing beef and crabs. It is 
probable that the same poison, ptomatropin, is the active agent." 

The poisoning resulting from the use of canned meats is often bac- 
terial in origin. Poison may also occur, according to the same 
authority, (i) in meat from healthy animals which has been improp- 
erly prepared or kept too long ; (2) in meat from animals which 
during life have suffered from bacterial infection. 

There are many examples. In man, the eating of such food, even 
though it has been boiled or roasted, gives rise to severe symptoms 
which Bollinger calls intestinal sepsis. The symptoms are due to 
the action of the poisons on the intestines and their absorption 
thence. Dozens and sometimes hundreds of men have been attacked 
at once from the use of such food. 

A sufficient number of similar experiments have been made by 
Vaughan in this country, apd others, to enable us to infer that pois- 
onous substances of deadly character may and often do occur in meats, 
milk, oysters, lobsters, crabs, and other moist albuminous foods. 
When these changes have gone so far that we are able to recognize 
them by bad-smelling gases, changes in color, consistency or reac- 
tion, then the danger is not so great, for well-disposed persons know 
from experience that such foods are unwholesome and cannot be eaten 
without danger, although it not infrequently happens that they are 
prepared for the table by the ignorant cook. 

The danger lies not only here but in the fact that without extra- 
ordinary care, changes begin at once in all of these foods, and that in 
the hands of the average worker they must often contain poisonous 
matter in small quantities which may not be destroyed by any method 
of cooking, and that foods of such a nature tend to depress the 
powers of the body, and if eaten for a length of time may so disturb 
the economy of the system, either by direct absorption into the cir- 
culation or by causing digestive disturbances, as to give rise to actual 
conditions of sickness, or to put the body in such a state of non- 
resistance to pathogenic organisms that disease easily gains a foot- 
hold. In addition to this, in cases where not diCi\x2\ poisonous matter 
is produced, fermentative changes may take place which destroy 
desirable nutritive and savory qualities in food. Changes of the 
last two kinds are the most to be dreaded because of their subtle 
nature and the difficulty of recognizing them, therefore the ordinary 
worker should be taught by some one who does understand the 
means of prevention. 



196 BOLAND. 

An article recently published by Dr. Cyrus Edson, on " Some 
Sanitary Aspects of Bread-making/' is in the line of this point He 
says : ** I have not the slightest cause to doubt that diseases have been 
and will be carried about in bread. I have seen journeymen bakers 
suffering from cutaneous diseases, working the dough in the bread 
trough with naked hands and arms. This is an exceedingly objec- 
tionable thing, from the standpoint of a physician, for these reasons: 
while it needs no medical knowledge to cause a person to object to 
having the bread he eats kneaded by a baker having cutaneous 
eruptions on his arms or hands, it does need this knowledge to 
understand that the germs of disease which are in the air, in dust, on 
stairways, and straps in street-cars, are most often collected on the 
hands. Any person who has ever kneaded dough understands the 
way in which the dough cleans the hands. In other words, this means 
that any germs which may have found a lodging-place on the hands 
of the baker before he makes up his batch of bread, are sure to be in 
the dough, where they find all the conditions necessary for subdivi- 
sion and growth. This is equivalent to saying that we must depend 
upon heat to kill these germs, since they are sure to be in the bread." 
He then adds : **I have not the slightest doubt that, could we trace 
back some of the cases of illness which we meet in our practice, we 
would find that germs collected by the baker had found their way 
into yeast-bread, that the heat had not been sufficient to destroy 
them, and that the under-cooked bread had been eaten with its colo- 
nies of germs, the call for the physician rounding off this sequence 
of events." 

Whether this will bear scientific investigation remains to be seen, 
since bread is generally subjected to a high temperature in cooking ; 
but whether it will or not, it is a valuable suggestion, as indicating a 
long line of possibilities in other kinds of food which are not sub- 
jected to so high temperature as that usually given to bread. 

In addition to this there is always the possibility of getting into 
the system, through the medium of food, the organisms of the various 
contagious and infectious diseases, such as tuberculosis, — the organ- 
ism of which may exist in the air, be blown about with dust and settle 
upon fruits, food and dishes, — typhoid fever, diphtheria, cholera, etc. 

A purveyor, housekeeper, superintendent or other person whose 
duty it is to look after the affairsof a hospital kitchen should be able 
to recognize all of these points. Of much importance in hospitals is 
a supply of unquestionably good milk, which should be stored in 



HOSPITAL DIETARIES. I97 

absolutely clean vessels, in a clean, well-aired refrigerator. It should 
be frequently tested for fat reaction and specific gravity, and in cases 
of epidemics, or when for any reason it is not above suspicion, it 
should be taken to a reliable chemist for analysis, or sterilized. A 
purveyor should be able to intelligently determine the quality of 
bread made, to prevent the use of alum and alum baking powders in 
it, as also the use of stale eggs, decaying butter, commonly called 
rancid, and carbonate of ammonia in cake, and he should be able to 
do for every other form of food what he does for milk and bread, 
that is, have an intelligent understanding of the nature of foods, and 
know the means by which they may be made and kept in the most 
wholesome condition. The question is here naturally suggested, 
where can be found a person willing to take such a position who 
knows enough of chemistry and bacteriology to appreciate these 
things ? My reply is, create the demand and the supply will be 
forthcoming. 

Twenty years ago, when an eastern State decided to have drawing 
taught in its public schools, the commissioners were obliged to send 
to England for teachers. Immediately, as soon as the demand was 
apparent, young men and women in this country began to study the 
subject, and in five years we had enough teachers of our own. 
Create the demand and the question of supply is only a matter of 
time. 

I might mention here that which scarcely needs to be said, that is, 
that the demand must come from the trustees and officers of institu- 
tions, otherwise there will be no change, no progress. The servant 
of himself will not change. We cannot look to him to do so. He 
never elevates himself, no matter what stress of need or coercion 
may be brought to bear upon him. He cannot, without opportunity, 
encouragement, instruction, none of which are at present accorded 
him. He often struggles to do so, but it is ever a struggle in the 
dark, and usually ends in perplexity. As for the patient, his voice is 
never heard in such matters, except in those hospitals fortunate 
enough to have paying patients whose presence and criticisms are a 
stimulus to all. 

Good quality and proper care of food materials and the most scru- 
pulous neatness of workers, working-rooms and utensils, are the foun- 
dations upon which any good system of dietaries must rest. 

After this we come to the consideration of system and order in 
methods of cooking. To illustrate this latter point we may select 



198 BOLAND. 

any line of dishes, — for instance, soups. A head-cook should have at 
hand a list of wholesome and simple soups (it is neither necessary 
nor advbable in a hospital to make the more elaborate dishes of any 
kind), which will vary somewhat according to the seasons of the 
year, but which in the main may be the same for the twelve months. 
I would advise dividing them into four groups, and if possible, no 
matter how acceptable it may be, that the same soup be served not 
oftener than once in two weeks, for the sake of securing sufficient 
variety. This is a much more simple matter to formulate than it 
seems. It requires only an intelligent head to plan, to direct, to criti- 
cise, and the thing is done. 

Chicken, Julien, oyster, clam, celery, mock-bisque, asparagus, pea, 
bean, lentil, consomm6, barley, and bouillon are familiar soups. These 
should be made according to some definite and exact rule which has 
been proved to be wholesome and savory. For instance, mock-bisque 
soup is a compound of tomatoes, milk, flour and butter, with soda, 
salt and pepper. Cooked tomatoes are strained and a pint measured. 
To this is added a teaspoon of salt, a fourth of a teaspoon of pepper, 
and an eighth of a teaspoon of bicarbonate of soda; the latter is used 
to partially neutralize the too strong acid of the tomatoes. The pro- 
cess is this : the tablespoon of flour is cooked in the tablespoon of 
butter, and a pint of milk added ; the pepper, salt and soda are 
mixed with the tomato, the sauce is then poured in, the whole 
strained, and the soup is done. This gives a quart of simple but 
wholesome soup and one which is usually acceptable to the sick. 
These proportions may be regarded as a unit rule by the multiplica- 
tion of which any quantity may be made. A quart of soup will 
furnish enough for five portions. If a hundred persons are to be 
supplied, twenty quarts will be required, and by multiplying each 
item in the unit rule by twenty and carrying out the process correctly, 
exactly the same quality of soup will be obtained. The formula 
for twenty quarts will be ten quarts of tomatoes, ten quarts 
of milk, twenty tablespoons or two and one-half cups of flour, two 
and one-half cups of butter, twenty teaspoons of salt (ten tablespoons) 
or one and one-fourth cups, two and a-half teaspoons of pepper, two 
and a-half teaspoons of soda. 

There are some precautions to be observed in using this rule. 

(i) If the flour is not cooked in the butter for a definite time 
before the milk is added in making the sauce, the flavor and quality 
of the soup are impaired, for the high temperature which the butter 



HOSPITAL DIETARIES. I99 

can attain changes the nature of the starch in the flour, rendering it 
both more palatable and more digestible than it would otherwise be. 

(2) The bicarbonate of soda must not be omitted, otherwise the 
soup will be too acid and will have a curdled appearance. 

(3) Any deviation from the proportions will cause a difference in 
the quality of the soup. It is difficult for the ordinary cook to see 
this, but it can be demonstrated to him. If the soup be made 
according to the formula its quality will be constant. It will not 
be too sour to-day, too salt to-morrow, too thick another time. 
This point is of great importance, for a vast amount of the waste 
of food materials is brought about because of this lack of constancy 
of good quality in the dish made, not to mention the harm wrought • 
by eating such food. 

In one of the thirty-one institutions mentioned, I took nearly every 
meal for a week. We had the same soup for dinner each day. One 
day it was good, another day it was burned beyond the possibility of 
eating, and on a third occasion the meat from which it was partly 
made was tainted. On the two last occasions nearly the whole of the 
soup must have been a complete loss, and certainly much better lost 
than eaten. On other days it was indiflerently bad, showing that it 
was made at the discretion of a very poor cook without any desire 
for the good of the eater whatever. 

It is a question whether such conditions are not criminal offenses, 
and when the eaters of such food fall into a state of fatal disease they 
should be spoken of not as having died but as having been killed by 
the sinful indifference of men and women in positions of power whose 
moral status is wholly insufficient for their responsibilities. 

Making soup according to an invariable formula which has been 
proved to be satisfactory may, to those who have always regarded 
the kitchen as a place of chaos from which by some mys- 
terious combination of circumstances dishes are evolved three times 
a day, seem difficult to inculcate, but it is in reality not so, provided 
there is somewhere in the domain a hand guided by an intelligent 
head. After a few trials a cook soon learns that it is infinitely easier 
to make according to rule rather than by guesswork ; the element 
of uncertainty in regard to result is eliminated, the quality of the 
dish will always be the same, there will be no necessity for tasting, 
no necessity for hovering over the kettle to see whether it is coming 
out right ; time is saved, and the pleasure which a satisfactory piece 
of work always gives will be attained. Of course the ultimate and 
most important thought is the welfare of the eater. 



200 BOLAND. 

My experience with cooks and other servants is that they are 
extremely anxious to learn when they find a teacher, and that they 
are extremely quick in discriminating between the reality and the 
sham, between those who really know and those who think they do. 

I have dwelt upon this single dish because it illustrates the 
method that should be followed in all cooking. Bread, vegetables, 
meats, puddings, in fact every kind of food that is made should be 
made according to a fixed and definite plan as to proportions, pro- 
cess and details of manipulation. Can this be accomplished in 
institutions ? If so, how ? I will say that it is not only entirely prac- 
ticable but that it is already practiced. It is in part carried out in 
t)ne institution which I visited, which it was my great good fortune 
by accident to learn about, as it by far and above all others excels in 
its cuisine. 

It is a sort of hotel for women, for working women of the better 
class, and entirely managed by women. Its various departments 
are conspicuous for their excellence, but most conspicuous of all for 
this characteristic is the table. I lived in this establishment for a 
week, and in no place, either in a private family or at an hotel, have 
I ever seen a more satisfactory table. The food was of excellent 
quality, of good flavor, satisfying and inexpensive ; the ordinary 
market food materials, by superior methods of cooking, having been 
converted into acceptable and health-giving food. The mid-day 
meal, a luncheon, is served to five hundred persons, so that it will be 
seen that the food must be cooked in large quantities. From the 
results seen I became deeply interested to learn the details of the 
plan of management ; for that there were both plan and system in its 
execution was {perfectly evident, — such results could not be accom- 
plished by haphazard. Through the courtesy of the managers I 
was " let in " to the secret workings of the kitchen and shown all 
the various details in cooking. 

The work is divided into two departments, that of the actual fur- 
nishing of food, and that of serving, each with a superintendent. The 
woman at the head of the food department does the marketing — 
buying all food materials and caring for their proper storage and 
preservation — perfects the formulae and criticizes the food when done. 
She takes, in a measure, the place of a teacher giving actual instruc- 
tion in the various divisions of her department — to the pastry-cooks, 
meat-cooks, etc. Do they resent this ? Not at all. The most friendly 
relations exist between those in authority and the servants. The 



HOSPITAL DIETARIES. 20I 

latter are glad to learn, their work is less worrying, their lives conse- 
quently more content and their service of more value. 

We had one day a delicious salad. On inquiry, I found that the 
formula for it had been worked out by the superintendent and cook 
together until it was perfected, and the proportions thus obtained 
constituted their working formula, from which no deviation was 
allowed to be made. 

The menus in this institution are interesting. Table d'h6te meals 
are regularly served, and also one may order k la carte, but the 
former are so acceptable that it is seldom one cares to order special 
dishes. The following is one day's menu (Saturday, April 22) : 

Tadl€ d'hSte Breakfast. — Porridge of oatmeal or wheat, beef- 
steak, soft-cooked eggs, Saratoga potatoes, griddle-cakes. 

Lunch, — Vegetable soup, scalloped oysters, potato salad, cold 
meats. 

Dinner, — Royal soup, roast veal, Irish stew, browned potatoes, 
corn, lettuce, rice-cups with custard, cottage pudding, oranges. 

With all the meals corn, Graham and white bread of exceptional 
quality are served, and tea, coffee or cocoa. This is simple but Well 
constructed and gives some opportunity for choice. A list of this kind 
is of but little value, however, in conveying ideas, unless one knows 
the quality of the food served; but when we find that the vegetable 
soup is of excellent quality, savory and satisfactory, that every morsel 
of it is eaten, that the scalloped oysters are above reproach, and the 
salad all that one could expect, the lunch becomes ample. Let us 
compare with this the following dinner menu found in one of the pay- 
wards of a hospital : 

Chicken soup, raw oysters, broiled spring chicken, sweetbread with 
toast points, roast beef, broiled fish, stewed tomatoes, stewed com, rice, 
mashed potatoes, hominy, peach pie, oranges. This is somewhat 
elaborate. Let us sample some of these dishes. The chicken soup 
tastes of the iron kettle in which it was made, and is very suggestive 
of not clean old bones ; two or three spoonfuls are enough. The 
broiled chicken is not well prepared, there are feathers on the out- 
side, and it is raw and red at the joints ; portions of the breast are 
nibbled, and the rest of what should be a most delicious food is 
thrown away. The sweetbreads savor of rancid butter, and they 
meet much the same fate as the chicken ; the corn, rice, potatoes and 
hominy all taste alike, and of the peach pie one is afraid to eat, 
because it has a flavor of tin, which can only be explained by the 



202 BOLAND. 

supposition that the fruit was allowed to remain some time in the can 
after it had been opened. 

Here we have an example of the failure to supply acceptable food to 
the eater, with every factor present except that of care and under- 
standing in cooking. Varied, wholesome, and valuable food mate- 
rial fails to fulfill its ultimate use. It is evident that money, energy 
and time in abundance have been put into the menu, and that they, 
in a measure, have failed to find an adequate value because of ignor- 
ance in the methods of cooking. I would suggest that the list be 
much simplified, and that some of the force here expended be 
diverted in the direction of perfecting methods, so that there may be 
sent to the bedside of every sick patient, food that is at Ipast entirely 
and absolutely wholesome, and prepared according to the very best 
possible methods known in these matters. 

We must take the initiative ; it is more or less our duty to do so. 
Our charitable institutions, especially hospitals, should be homes in 
which there is less suggestion of that cold charity which the world 
practices, and more of the new charity which has already begun to 
dawn in places, — the charity of the close of the nineteenth century, 
which as yet is a tiny blossom, but which with hope and joy we look 
forward to as the only kind which shall characterize the morning of 
the coming century which is so near ; — that charity which has a liv- 
ing interest in the welfare of its object, which seeks to restore him to 
perfect physical and mental health and vigor, — to put him upon his 
feet again, so to speak, that he may have strength and courage to 
battle with the world and honestly earn his daily bread. 

Hospitals should keep high standards of what restoring to health 
means. Some men, it is true, are wrecked to such an extent that a 
perfect state of health can never again be possible for them ; but for 
those who are not wrecks, for how many of them is this done? 

In one hospital characterized by the barbarous condition of its 
cuisine, in which condensed milk is the only milk furnished the 
sick, and bad bread without butter and boiled cheap tea without 
milk constitute the evening meal of those able to eat, — I was told on 
inquiring what food was planned for convalescents, that they never 
had that class of patients, that as soon as a man could sit up he was 
sent home, and then my informer naively added, " But it is a bad plan ; 
they are always coming back to us." 

In presenting this subject to you I hope I have not been too radi- 
cal. Should it seem so, I entreat you to study it for yourselves in 



HOSPITAL DIETARIES. 203 

every possible light and phase, with the assiduity and methods of a 
scientist, until point after point are known with exactness ; and if this 
paper arrests the attention of only one among you sufiiciendy to do 
this it will not have failed in its object. 

Discussion. 

Chairman. — ^The last two papers are now before the Section for 
discussion. In regard to Miss Boland's paper, it is a melancholy 
presentation of the conditions in some kitchens. It is true that bac- 
teria are all about us, but if the bacteria were not there we should be 
in a very much worse condition. Every person in this room has 
millions and millions of bacteria in him or her, and if it were not so 
they would be very sick indeed. The immense majority of micro- 
organisms are healthful and not harmful. The fluids of the body and 
the mucous canals all contain them. But it is the dangerous bacteria 
we have to look to. This does not militate against what Miss 
Boland said about the necessity of cleanliness throughout the kitchen, 
but cleanliness is to be maintained without any special reference to 
bacteria. I don't see the force in Dr. Edson's statement that there 
are bacteria in the bread. Of course there are bacteria in the bread, 
and on the outside of it too. There are bacteria in every breath 
of air you draw. It is housewife cleanliness that you should observe, 
not bacteriological or chemical cleanliness. 

The last part of Miss Boland's paper I think most excellent. The 
greatest addition we want to our knowledge now is constructive 
knowledge — to tell how to do things. 

Mr. Burdett.— I want to say a word on this question of hospital 
dietaries. It is a most important one. I think Miss Boland's paper 
is a most valuable one, because it focuses the present state of 
things, and will bring home to the minds of people not familiar with 
the subject the exact facts ; and I think further that those of us who 
have had the pleasure of reading Miss Boland's book and of visiting 
the Johns Hopkins Hospital and seeing her work there, will recognize 
that we owe her a debt of gratitude. I would like to say further that 
I personally feel most grateful that in this section we have had a hos- 
pital physician who has gone out of the ordinary path of his work 
in order that he might emphasize as a medical man the importance 
which he attaches to this very question of diet-kitchens in hospitals. 
I think that is a fact which shows development in the right direction. 



204 ABBOTT. 



A DESCRIPTION OF THE PROPOSED NEW LAUNDRY 
OF THE UNIVERSITY OF PENNSYLVAVIA 

HOSPITAL, 

IVM Special Remarks and Experiments upon Disinfection in 
canmciion with the Work of Hospital Laundries, 

By a. C. Abbott, M. D., 

First Assistant in the Laboratory of Hygiene^ University of Pennsylvania, 
(From the Laboratory of Hygiene, Unirersity of Pennsylrania.) 

The laundry that is about to be constructed for the University of 
Pennsylvania Hospital, the floor plan of which accompanies this 
paper, has not been designed with any special views to architectural 
effect, but rather as a building arranged for work of a particular 
character. It is to be supplied with all necessary apparatus of mod- 
ern pattern that is essential to the saving of labor and the proper 
performance of the functions of this department, and has been 
arranged with the special view of putting into practice those methods 
in the management of hospital laundry work that are essential in 
preventing the dissemination of disease through this channel. 

The building, when complete, will be a one-story structure located 
upon the lawn of the hospital, within easy reach of the back entry. 
It is, roughly speaking, to be 90 feet long by 50 feet wide, and at the 
ridge of the roof has an elevation of«i8 feet. 

The ceilings throughout are to be 10 feet high. All rooms are to 
ventilate into the loft between the ceilings and the roof, from which 
the air is allowed to escape through a slatted cupola. The walls are 
to be of brick, 13 inches thick, plastered but not furred on the inner 
surface. The floors are to be of concrete, with a fall towards central 
openings for drainage. The building is divided into two compart- 
ments ; the one marked A in the accompanying plan, having a floor 
surface of 48 by 20 feet, not including a drying room of 26 by 8 feet 
in area, is a private laundry in which the clothing of the resident staff 
and possibly that of a few private patients will be laundried. 

This section of the building is not in communication with the 
public laundry. It is entirely independent of it, being provided with 
its own drying room and all apparatus necessary for the performance 
of the work coming within its scope. 



» ^ 


p 


1 


o 


1 '^ 




LAUNDRY OF THE UNIVERSITY OF PENNSYLVANIA HOSPITAL. 20$ 

The remaining space B and C will be devoted to washing and iron- 
ing the articles from the public wards. The room B is the wash- 
room proper, in which will be located three mechanical washers and 
a mechanical wringer or centrifugal machine. The room is 48 feet 
long by 25 feet broad at one end and 46 feet broad at the other, and 
is in communication with a drying chamber (/^) that is 26 feet long 
by 8 feet broad. 

Room C is the ironing room, in which will be located the mangle 
^nd tables for hand work. It has a floor surface of 21 by 44 feet, 
and is abundantly supplied with light. Each place at the ironing 
tables in this room is to be provided with a gas heater for the irons, 
as no stove for the purpose is to be used. The use of gas is prefer- 
able because the individual can better regulate the temperature of 
the iron than when it is placed upon the stove. On the stove the 
iron commonly becomes overheated and is then cooled by dipping it 
into cold water, much to the detriment of its smooth, polished surface. 

The spaces G and H are the drying-rooms for the private and 
public laundries respectively. They each have an area of 234 square 
feet, and will be provided with the ordinary sliding clothes-racks 9 
feet in height. Between these racks there will be vertical, direct 
radiation drying coils, having a radiating surface in proportion to 
the air capacity of the chamber of about i square foot to 5 or 6 
cubic feet of air; this, under steam pressure of 55 to 60 pounds, with 
properly proportioned inlet and outlet openings for ventilation, 
should insure complete renewal of the air in these rooms about twice 
per minute. 

It should be needless to emphasize the necessity for high tempera- 
ture and rapid ventilation for drying purposes, for the conditions 
calling for them are, on physical grounds, too obvious ; but it is not 
uncommon to see such rooms arranged with coils for heating the air 
but with no provisions at all for permitting its escape when it has 
become saturated with moisture and no longer effectual as a drying 
agent. That drying-rooms constructed in this way do serve the 
purpose for which they were designed is due entirely to the natural 
exchange of air that occurs by leakage through cracks and crevices, 
but the amount of work that they are capable of doing in removing 
moisture under these circumstances is not by any means commensu- 
rate with what they could do had they the proper arrangements for 
permitting the free escape of the saturated air with an equivalent 
ingress of air less rich in moisture. The drying-room of a laundry 



206 ABBOTT- 

is no more complete without means for adequate ventilation than 
would be a drying-kiln for lumber without a fan for fordng air 
through it. 

Room E is the disinfecting chamber provided for the steam disin- 
fecting apparatus. It communicates with the laundry only through 
the apparatus, the idea being that infected clothing or mattresses, 
when brought into this room, shall reach the laundry only after hav- 
ing been subjected to the disinfecting action of steam. 

Room /" is a rinsing room in which chemical disinfection and sub- 
sequent rinsing of the disinfected articles can be performed before 
they are permitted to pass into the laundry proper. It will also con- 
tain a metal caldron provided with steam coils for disinfection of 
small articles by boiling, when it is not desirable to operate the larger 
apparatus. 

Over rooms D, E and F is to be a second story, consisting of a 
single room in which mattresses and bed-clothing can be stored, 
aired, etc. It will be reached by a covered stairway located on the 
outside. 

It is not the province of this communication to discuss the various 
methods of washing clothes, but rather to impress the importance of 
hospital laundries as factors in preventing the spread of contagion. 

Those who are interested in the management of institutions 
intended for the care of the sick will, I think, agree thai there are 
few departments of a hospital more potent for good in preventing the 
dissemination of infectious diseases, when well and properly man- 
aged, or more liable to do harm when badly conducted, than is the 
laundry. It is here thai are brought underclothing, bed-clothing, 
mattresses, and in some instances dressings from patients, many of 
whom are at times afflicted with diseases of a communicable charac- 
ter, and unless the necessity for special precautions intended to render 
harmless such materials is appreciated, harm may result, and such 
doubtless often has been the case. 

The functions of the laundry are not limited to the space confined 
within the boundary of its walls, for it is not alone the treatment 
received by infected clothing when in the laundry that is of import- 
ance, but of equal moment are the precautions to be taken in remov- 
ing it from the patient and conveying it from the ward. In these 
respects the greatest care is to be exercised by the attendant to 
whom the duties fall, in order that neither he himself nor olhers in 
the vicinity may become infected, A number of plans, having for 
their object the removal of infected clothing from the wards of hos- 




LAUNDRY OF THE UNIVERSITY OF PENNSYLVANIA HOSPITAL. 20/ 

pitals to the laundry, have been suggested, but relatively few of 
them are put to practical use. The plan to which we give preference, 
because of its safety and simplicity, is as follows : All bed-clothing 
and underclothing that are stained with evacuations from the intesti- 
nal canal, whether they are of an infectious nature or not, also all 
articles stained with discharges from wounds, are, upon their removal 
from the patient, to be placed at once into a covered vessel contain- 
ing a disinfecting fluid that has been brought to the bedside, and 
they are to remain in this solution until the time necessary for disin- 
fection has expired before they are permitted to be washed with 
other clothing. 

Objections are occasionally raised to this method of procedure on 
the grounds that the action of chemical disinfectants is often that of 
a mordant for white goods stained by blood, faecal matters and dis- 
charges from wounds generally, and for this reason the method has 
not met with general favor. As opposed to these objections, the 
advantages possessed by it are obvious, viz. the clothing is not car- 
ried through the ward in a dry condition, but is placed, immediately 
upon its removal from the patient, into a covered vessel containing 
a reliable disinfectant, and after a very short time is harmless and can 
be handled without danger of spreading infection. In view of these 
advantages I have endeavored to determine experimentally how far 
the objections to this method are based upon fact. 

In my experiments which were made upon flannel, canton flannel 
and muslin, stained both by blood and by intestinal discharges, a 
number of interesting and instructive results were obtained. The 
disinfectants with which I have made the experiments were moist 
heat, in the form of hot water, and steam ; carbolic acid in 3 per cent 
solution ; a mixture of 3 per cent carbolic acid and 1.5 per cent 
ordinary laundry soap in water; and 0.5 per cent solution of chloride 
of lime in cold water. Throughout, the strengths of the agents 
employed have been sufficient to ensure disinfection of non -spore- 
bearing pathogenic organisms within one-half hour. 

The results that I have obtained, stated in brief, are these, viz. 
white goods, including muslin, flannel and canton flannel, when 
stained with blood or intestinal discharges, and the stains allowed to 
dry, and subjected to either hot water at a temperature of from 
176® F. to the boiling-point, or when immersed for two hours in a 
solution of corrosive sublimate of the strength of i to 1000, have 
their stains so fixed that it is impossible to remove them subsequently 
by any of the ordinary methods employed in laundry work. Car- 



208 ABBOTT. 

bolic acid of the strength of 3 per cent solution in cold water, alone 
or plus the addition of 1.5 per cent common laundry soap, which 
renders the acid more soluble, does not have the property of fixing 
these stains indelibly, even though the goods may be soaked in this 
solution for as long as 18 hours. 

Chloride of lime in the proportion of 0.5 per cent solution in cold 
water has also no effect in fixing the stains, and has likewise appar- 
ently no injurious action upon white fabrics that are exposed to it 
for a period of one hour. It is to be borne in mind that satisfactory 
results in disinfecting bed-clothing and underclothing by this method, 
and at the same time ridding them of all unsightly stains, are only 
to be obtained when the entire process is carried on at a temperature 
not exceeding 100° F., for, as I have demonstrated, blood-stains and 
stains of intestinal evacuations, when partly removed from white 
goods by soaking them for from one to two hours in cold disinfectant 
solutions, may still be rendered partly indelible by the subsequent 
action of hot water. 

They should therefore, when the time necessary for disinfection 
has passed by, be removed from the disinfectant solution and thor- 
oughly rinsed in cold soap and water until all traces of the stains 
have been removed ; they can then be subjected to the usual pro- 
cesses of the laundry. I have found that blood-stains, both recent 
and old, are, contrary to what I had expected, more easily removed 
from white goods than are the stains of faecal matters; the latter, 
even when recent, but dried, are exceedingly difficult to remove. For 
the removal from white cotton goods of stains of this character, and 
at the same time for their complete disinfection, the solution of 
chloride of lime of the strength of 0.5 per cent acting for one hour 
has given me the best results, but it is open to two objections — ^first, 
the difficulty of obtaining a preparation of this substance in which the 
proportion of available chlorine is at all constant, and secondly, the 
objection frequently raised, for which I cannot vouch, that prepara- 
tions of chlorine, when allowed to act repeatedly on cotton and 
woolen fabrics, cause them to deteriorate. 

For these reasons I have given the preference to the mixture of 
carbolic acid and soap as recommended by Nocht (Zeitschrift f(ir 
Hygiene, Bd. VII, 1889). The strength of the mixture is: 

Carbolic acid, 3 parts. 

Common soft soap, li to 2 parts. 
Cold water, 100 parts. ^ 



LAUNDRY OF THE UNIVERSITY OF PENNSYLVANIA HOSPITAL. 2O9 

The soap is to be dissolved in the water, after which the acid is to 
be added and the mixture thoroughly stirred. Experiment has 
shown that in this strength all non-spore-forming pathogenic organ- 
isms are destroyed in one half- hour. 

Another mixture that is sometimes recommended, and upon which 
I have made a few experiments, consists of equal parts of crude car- 
bolic acid and concentrated sulphuric acid dissolved in water to the 
required strength ; this is not to be recommended for laundry pur- 
poses, as it not only gives rise to an unsightly, dirty-yellow discolor- 
ation of both cottons and woolens, but has also, in my experiments, 
had some effect in fixing the stains. This preparation of carbolic 
acid is, moreover, of very doubtful value in the proportion of phenol 
contained in it, is but a few cents per pound cheaper than commer- 
cial carbolic acid, and, as just stated, possesses disadvantages which 
at once exclude it from use in the laundry. There are three grades 
of carbolic acid usually on the market, viz. the crude, the commer- 
cial and the chemically pure. The first is excluded from use for the 
reasons just given, while the third mentioned is relatively too expen- 
sive; the second, the commercial carbolic acid in the strength given, 
answers perfectly well for all practical purposes. 

Note, — Samples of materials of different character that have been stained 
with blood and with faecal matters, and subsequently treated by the chemical 
methods just referred to, accompanied this paper. Each sample was labeled, 
and the results of the various methods could be seen. 

From these experiments it is manifest that chemical disinfection 
carried on at a temperature not exceeding 100® F. is to be preferred, 
and that all efforts at disinfecting these articles by heat, in any form 
whatever, must necessarily result in permanently fixing the stains. If 
it is proposed to rinse out the stains prior to subjecting them to the 
disinfecting action of steam or boiling water, it is evident that the 
process of rinsing must be carried on at a time when some, at least, 
of the articles are capable of causing infection. Another advantage 
in favor of this method is that it does not require the employment 
of a disinfecting apparatus, an advantage readily appreciated by those 
having access to suph a plant. 

For larger objects, such for example as mattresses or outer wear- 
ing apparel, the method of chemical disinfection is obviously not 
applicable, and only steam should be employed. Much has been 
said in regard to steam disinfection and the requirements of the 
apparatus designed for this purpose, but unfortunately it has been of 



2 lO ABBOTT. 

such a character as to leave the impression that a steam disinfector 
is necessarily a complicated and expensive apparatus, and in order 
for all theoretical requirements to be fulfilled perhaps it is, but a 
boiler-iron cylinder of the necessary capacity, placed horizontally, 
with swinging doors at either end, an inlet for steam at the top and 
a valved outlet for air and water of condensation at the bottom, will 
be found to answer all practical purposes, providing it is intelligently 
operated; and no hospital laundry is complete without such an 
apparatus. 

In size it should be capable of accommodating at least two or three 
mattresses or their equivalent bulk of clothing. It may be either 
circular, oval, or rectangular in cross section, and should be located 
horizontally in a room especially provided as a disinfecting chamber. 
It should be provided at either end with a door that when closed 
can be clamped and the joint thus practically hermetically sealed. 

It should stand in the disinfecting room in such a way that only 
one end is accessible from the room, while the other end can only be 
opened from the laundry, there being no communication between the 
disinfecting room and the laundry except through the disinfector, 
which will always be closed, unless for the removal of articles dis- 
infected, or the reception of articles to be disinfected. 

It is sometimes undesirable to place an apparatus of this size in 
operation for the disinfection of a few things from a single patient, 
and in this event, if heat is insisted upon as the method to be used, 
a covered metal caldron of 40-60 gallons capacity, provided with 
steam coils, so that the water contained in it can readily be brought 
to the boiling point, will be found of great convenience. 

There is no doubt that some or perhaps all of these directions will 
be called into question because of their not taking into account certain 
theoretical details that are considered necessary in order that disin- 
fection may be complete. 

Disinfection as practiced upon such resistant test objects as the 
spores of the bacillus anthracis might possibly not be complete if 
attempted by any of the methods that have been recommended in this 
paper, but it is seldom that objects of this character are to be dealt 
with in ordinary hospital work. The infectious agents requiring most 
frequent attention in hospitals, such for example as clothing soiled 
with the dejections of typhoid patients, the soiled clothing from 
diphtheria and tuberculosis patients and the articles from surgical 
cases, will be readily rendered safe by any of the methods here 
recommended. 



laundry of the university of pennsylvania hospital. 2 1 1 

Discussion. 

Dr. J. Lm Notter, of Nedey, England. — ^There are one or two 
points I should like to be very clear on, and that is the use of terms. 
This term *' disinfectant " — there is no more misused word than thaL 
What do we mean by disinfectant ? We mean some chemical agent 
which destroys specific poison. Now it is not to be confounded with 
an antiseptic ; and the mere staining of clothing, which I take is the 
principal object of exhibiting these samples here, which is the result 
of chemical action itself, whereby albuminous substances which were 
thrown out in the discharge have been coagulated by the application 
of heat, is of little importance. The simplest metliod when you have 
a discharge to deal with is to receive the sheets or clothing into a 
solution of mercuric chloride, then subsequently treat the articles in 
the ordinary way. It is not the chemical action that causes these 
stains ; they are simply produced by heat ; it is the fixing of the 
albuminous compound in the infected clothing due to the dischargea. 

Now as to the question of disinfectant Too much reliance has 
been placed upon them, that is my own personal experience. Disinfect- 
ants are good, but cleanliness is better. When I go into a hospital 
and smell disinfectants I am suspicious. The best destroyer of 
infected matter is one-half an ounce mercuric chloride, two or three 
ounces hydrochloric acid, three gallons of water. The addition of 
hydrochloric acid prevents the mercury from doing any damage. 

As to carbolic acid, I have carried on a great number of experi- 
ments. It is useful in some cases, but you must have it in not less 
than five per cent solution. 

I used in India, for the destruction of the cholera bacilli, five per 
cent carbolic acid, and found it a fairly good disinfectant ; but we 
preferred the mercury, in the acid form, for the typhoid. 

As regards heat. Now disinfecting chambers are not always avail- 
able. Wherever they are available they should be used. Not only 
is it desirable for the clothing, but for the beds and bedsteads, and 
for everything with which the patient comes in contact, that may 
require steam or atmospheric pressure, a little above atmospheric 
pressure, to destroy any germs which it may contain. 

These are, I think, the principal points that are dealt with. I most 
strongly recommend caution about accepting the results of expe- 
riments and thinking you have destroyed contagion simply because 
you have taken out the color. My own experiments do not lead me 
to place value of any consequence upon chloride of lime. 



2 1 2 GATEW'OOD. 

D2. Billings. — For the disinfection of clothing, bedding, towels 
ar.<2 ^.e-ything that can be boiled without injury, the simplest and 
rr.cs: certain method is to boil them. But if clothing soiled with 
o'cK/! and discharges from wounds, or from the intestinal discharges, 
!>£ a!! owed to dry, and is then put into boiling water, a permanent stain 
or discoloration will be produced. The articles to be boiled should 
g'> to the laundry without being allowed to dry. If soiled articles 
are put into cold water for two hours without any chemicals, the pig;- 
ments will soak out, and then you can put them into hot water, boil 
them and thoroughly cleanse them without fixing a stain. 

In a great hospital receiving cases of typhus and typhoid fever and 
other intectious diseases, the general laundry receives bedding and 
clothing from all such cases, and these articles are washed, rubbed 
and boiled together, yet there has never been a case of infection 
known to be traceable to the articles treated in the laundry. I believe 
that there is no danger of infection in a hospital laundry where every- 
thing goes in together — the clothing of the doctors, nurses and 
patients. But there is a feeling of repugnance to such a mixture 
which I think should be recognized, and in every large laundry it is 
recommended, as in this paper, to have the articles of the physicians 
and attendants go to a separate laundry for treatment. Keep the 
washing of the sick person separate from the washing of the others, 
but not by reason of any bacteriological necessity, because it cannot 
be defended on that ground. 



NOTES ON NAVAL HOSPITALS, MEDICAL SCHOOLS, 

AND TRAINING SCHOOL FOR NURSES. WITH A 

SKETCH OF HOSPITAL HISTORY. 

By J. D. Gatewood, M. D.. United States Navy. 

A Sketch of Hospital History. 

Many Christian writers and speakers, both lay and clerical, have 
claimed and are claiming for Christianity the origin of hospitals. 
They picture in glowirg language this birth as springing from the 
divine injunction to heal the sick, and from the elevating and soften- 
ing influence upon the hearts of men of this beautiful religion of our 



NOTES ON NAVAL HOSPITALS. 21$ 

land. One is forced to believe that such statements are made with- 
out sufficient investigation, as no teacher can afford to build upon 
any other foundation than that of truth. 

The Jews also have made a like contention, though it would ap- 
pear, upon a little reflection, that all civilizations and all cultured 
religions have been associated with the growth of that compassion 
for suffering which, though at times latent, is an inherent quality in 
man. It is to this growth that we must look for the origin of hos- 
pitals, and indeed for much of the effort of the medical mind in all 
ages and nations to heal the sick and the suffering. 

The pages of history are open to all, and though, in looking 
through the centuries, formless ashes are almost everywhere, shapes 
may still be found to more than suggest the beautiful thoughts and 
deeds of the human mind from almost the very beginning of this 
never-ending tragedy of life. 

The study of this question should begin with that of the physician, 
for no individual or state would evolve the idea of a hospital with- 
out the suggestive existence of minds equipped and available for the 
performance of hospital duties. Yet, in this short paper, the account 
of the beginning and rise of that interesting and remarkable person- 
age must be very incomplete. 

It is true that in remote antiquity there was, in some parts of the 
earth, a realization that certain diseases were curable. The people 
of the far and sunny East had, among other dreams, that of the 
removal of the hand of suffering and death from certain cases. The 
sick were exposed on couches in the public places, that they might 
have the benefit of the experience of the masses. It must have been 
an interesting spectacle — this approaching of the restored ones to 
the couches of the sick — to hear their complaints, to listen to the 
statement of symptoms, that those who had been similarly afflicted 
might impart the method of their cure. Thus so early in the story 
of life do we find an extensive attempt to use the guiding hand of 
experience. 

The sight must have impressed the minds of men in many different 
ways and degrees, and the most educated and observing ones would 
soon begin to collate methods and results. The empirical led to the 
question of why, and the question led to the study ; and the study 
of one set of questions by a few always creates a class. 

In this case it was a class within a class — the priest-physician. 
This result is not surprising when one recalls how many centuries 



214 GATEWOOD. 

were to pass before the mind could be prepared for the separation 
of medicine from magic,;divination and priestcraft. 

So it happened that we find the Egyptians writing systematically 
on medical subjects as early as the 14th century B. C. This med* 
ical papyrus in Berlin contains a treatise on inflammation and other 
subjects, and gives color to the claim of the Egyptian^ to the inven- 
tion of medicine. This wonderful people, working out their ideals 
under the fostering care of their profound religion, soon had a corps 
of medical men of the sacerdotal order, paid by the state, and as 
early as the nth century B. C. there was in that land a college of 
physicians in receipt of public pay. 

The physicians, required by the state to treat the sick poor, prac- 
tised their healing'art in every direction ; but it cannot be supposed 
that they could visit their patients except in particular and grave 
cases. There were, therefore, establishments set apart by the state» 
to which the masses could repair at fixed hours. Here we come to 
the beginning of dispensaries — an interesting fact, as it may be taken 
as a maxim that the hospital is the development of the dispensary. 

The exbtence of such institutions in that land of high ideals, excites 
no surprise when one reads on their sarcophagi such remarkable 
epitaphs as the following : " He succored the afflicted, gave bread 
to the hungry, drink to the thirsty, clothes to the naked, shelter to 
the outcast, that he opened his doors to the stranger, and was a 
father to the afflicted." So this land had long become famous, and a 
few inquiring minds from the less advanced countries of the North 
came to seek knowledge. 

Thus it is with no surprise that in the early history of Greece we 
find votive tablets on the walls of the temples. These, while 
exhibiting the superstition of the age, exhibit also, in some degree, 
the medical work of the time. They record the history and treat- 
ment of individual cases, and are in evidence of the crowds of sufferers 
who flocked to the temples of i^sculapius at Cos and Tricca, to 
dream at the foot of the altar and be guided by the advice of their 
priests. 

There is no proof, however, that these particular accounts relate to 
the poor of that country; on the contrary, they probably express the 
thanksgivings of the owners of goods and chattels. Yet they were 
histories of cases, and, one might say, leaves of the medical books of 
the time. 

In the fifth century B. C. the people of Athens were electing and 



NOTES ON NAVAL HOSPITALS. 21$ 

paying physicians and building dispensaries and hospitals. One of 
these latter, it is stated, was situated at Piraeus. Physicians and 
surgeons had, however, appeared in the history of Greece and Rome 
much before this ddte, and accounts of them will be found scattered 
through the history of that time. Pythagoras had visited the East ; 
and Hippocrates had appeared, to become the great clinical observer 
and writer, and to separate Greek medicine from priestcraft. 

The Romans were behind the age in refinement and culture, still 
one is not surprised to find that at the defeat of the Hetrurians 
(483 B. C.) the wounded Romans were quartered, by the order of 
the consul Fabius, at the houses of the senators. It was the custom 
in those days, and had been and was to be for many years, to place 
the sick and wounded in the houses of the citizens. However, before 
the time of Hadrian, there probably were government institutions 
among the Romans for the care of those injured in the defense of the 
state, though there seems to be no record of such before that period. 

But to return to earlier times and a more imaginative and profound 
people. In India, the history of hospitals many years before the 
Christian era is most clear and conclusive. The great king Asoka, 
who died in the third century B. C, established by royal edict 
these institutions on the routes of travel throughout his dominions. 
This edict, it appears, is still to be seen bearing the date 220 B. C. 
It was cut on a rock in Guzerat, probably by his successor. It states 
that " they shall be well provided with instruments and medicines, 
consisting of mineral and vegetable drugs, with roots and fruits; and 
that skillful physicians are to be appointed to administer them at the 
expense of the state."* These hospitals were founded at that time 
(220 B. C.) and continued their good work for more than eight hun- 
dred years, when their walls crumbled, after the government under 
which they existed had passed away. 

Here one might mention another civilization which goes back Co 
remote antiquity, and whose origin is shrouded in a mystery that 
provokes the research of our own time. The land of this people was 
Mexico. Prescott states, on several authorities, that hospitals were 
found among that ancient and remarkable race. These hospitab 
were erected and supported by the government, and, as he expresses 
it, were " for the care of the sick and the permanent refuge of dis- 
abled soldiers." The date when these people constructed their first 
hospital is a part of the Mexican mystery, but the existence of such 

* Review of the History of Medicine ^ by Thomas A. Wise. London, 1867. 



2l6 GATEWOOD. 

institutions in that unknown land is a further proof, if any were 
needed, that out of all civilizations and all cultured religions comes 
the growth of that compassion for suffering which is an inherent 
quality in man. 

In the earliest history of the Hebrews the priests were the physi- 
cians and surgeons, as has been the case with all races. The Scrip- 
tures (Genesis xvii) give the first recorded surgical operation after 
the Flood, and (Leviticus xiv) show the relation in very remote 
times of the physician-priest to the people in matters pertaining to 
the preservation of the public health from the attacks of contagi- 
ous and infectious diseases. The Bible (Exodus xxx) also mentions 
the apothecary at an early age, and (2 Kings xx) exhibits the method 
of treatment in a certain class of cases. It is interesting to observe 
how early in the history of this ever-memorable people the physician 
was separated from the priest (Jeremiah viii). These references 
might be multiplied, but they do nothing towards showing that any 
provision was made for the treatment of the sick at the public 
expense. Yet, considering the character of the Hebrews, there must 
be some record of such provision at some time early in their history. 

Returning to less remote ages, it may be observed without sur- 
prise, as Rome drew many of her inspirations from Greece, that, 219 
B. C, a surgery was provided at the public expense, at the Acilian 
Cross way, for a certain Greek physician, who came to exhibit the 
greater advance of his countrymen, and that, as the years rolled by, 
such places became more common in that land. When Vesuvius 
threw a pall over the fair city of Pompeii (Aug. 23, A, D. 79) it 
covered a hospital ; and centuries after, when an investigating race 
uncovered this interesting building, it was found to consist of a large 
room — the full depth of the house — divided in part into small rooms 
on each side of a passage. In one of these rooms many surgical 
instruments, now displayed in Naples, were discovered. These con- 
sist of "scalpels, scrapers, elevators, forceps, drills, and a well-made 
vaginal speculum." Had some benevolent pagan erected this build- 
ing for the care of the afflicted, or was it a private institution for 
those able to pay ? It was a hospital at any rate, and is worth 
recording on account of its early appearance in the land of the 
Caesars. 

As early as the 2d century A. D. there was an organized medical 
corps in the Roman army, though physicians and surgeons had long 
accompanied, in a somewhat desultory way, the armed forces of 



NOTES ON NAVAL HOSPITALS. 21/ 

all nations. Xenophon (about 400 B. C.) alludes to them in connec- 
tion with the Greek armies. As has been said, mention is made of 
a government hospital for the wounded in war during the reign of 
Hadrian (i 17-137 A. D.). In an order of Aurelian (270-274 A. D.) 
to his soldiers occurs the following: "Let the soldiers be cured 
gratuitously by the physicians, and let them conduct themselves quietly 
in the hospitia; and he who would raise strife let him be lashed." 
In the 2d century mention is made of the valetudinarium in camps, 
and the proper place for this camp hospital is indicated in plans for 
winter quarters. In the century preceding, it would seem that the 
wounded were, as a rule, placed in their tents ; as generals are men- 
tioned who excited admiration by visiting from tent to tent the 
wounded under their command. 

Tombstones have been found in England and Rome erected to the 
memory of members of the medical staff of the Roman army in the 
2d century, and in Dresden there appears a tablet " discovered in 
the Elysian fields near Baiae, in the vicinity of the famous Pontus 
Julius, and the station of the imperial Misenian fleet, which is to the 
memory of M. Satorius Longinus, physician to the Cupid, a three- 
banked ship." Though this is later, there is reason to believe that at 
a very early age vessels of war were provided with medical officers, 
and that the sick and wounded of the navy were received into insti- 
tutions erected by the government for them, before the time of 
Hadrian. 

There could be no Christianity without effort to help the poor and 
the suffering. This is a fundamental and essentia] part of the teach- 
ings of Christ. The Christian life began with it, and the care of the 
poor, the sick and the outcast has been the care of His Church and 
His people from the beginning. It seems the natural outcome, then, 
that so soon as the believers in this beautiful religion could acquire 
property with any reasonable expectation of remaining in possession, 
the hospital should be made to hold high the flag of the cross. So 
we learn without surprise that, as the 2d century was about to expire, 
the Christians seized the idea of hospitals in a practical way, and 
that their efforts increased as the years rolled by. As early as 300 
A. D., several hospitals were founded near Bethlehem under the 
direction of St. Jerome. 

Some of these buildings were retreats for the poorest and meanest, 
the most diseased and despised — the leper — and were thus a fit expo- 
nent of the Christian teaching. Others were used, together with 



2l8 GATEWOOD. 

those on the roads to Jerusalem, for the accommodation of pilgrims 
and the treatment of the sick. 

A few years after this, the influence of Jerome had extended to 
more distant lands, and his friend, the Roman lady Fabiola, expended 
her wealth in founding in the city of the Caesars a house for the q>e- 
cial care of the sick. In the Council of Nice, early in the 4th century, 
hospitals were spoken of with the greatest enthusiasm, as represent- 
ing a glorious part of the church work. 

Indeed, so strongly had their influence been felt, that the very 
intellectual Julian "The Apostate," in hb endeavors to re-establish 
the religion of his ancestors, availed himself of the power of hospitals, 
by establishing inns for travelers, the indigent and the sick of all 
creeds and nations. 

The famous hospital of Qesarea was founded 370 A. D., and the 
Hotel Dieu in Paris, 600 A. D. Many if not most of these buildings, 
prior td the nth century, were utilized to encourage pilgrimages, 
and thus excite religious enthusiasm ; but they were also equipped 
for the treatment of the sick and the sheltering of the poor. They 
were also, in almost every instance, church institutions, and were 
employed, among other things, to propagate and extend the teach- 
ings of that church. 

As cathedrals and monasteries were constructed to hold higii the 
cross all over the European world, hospitals were built close to them 
and were under the supervision of the bishops and monks. This 
consideration is an important one, because it has had much to do 
with the plan and construction of hospitals. The chapel became the 
most important part of the hospital establishment, and around this 
all the other buildings clustered. This was also true of many of the 
convents and monasteries, and furnishes us with the origin of the 
block plan. This idea of bringing the sick in close contact with the 
chapel, where they might hear the masses and see the processions, 
that their hearts, already troubled by sickness, might be touched by 
religion, culminated at the building of the Grand Hospital in Milan 
in 1456, when the Church of Rome was at the height of its power. 

It is a matter for interesting speculation as to how long hospitals 
would have been constructed on that plan, if there had not come the 
separation of hospital and church. But Christendom was in the next 
century to experience that great religious convulsion known as the 
Reformation, from which was to come a long period of independence 
in thought and action. Strangely enough, at the same time, Henry 



NOTES ON NAVAL HOSPITALS. 2I9 

VIII of England, that fearfully eccentric "defender of the faith,** was 
confiscating church property and converting certain abbeys and 
monasteries into hospitals ; thus starting in the hospitals of St. Bar- 
tholomew and St. Thomas that separation which was to become 
greater with each succeeding year. 

However, much time had to pass before the influence of the old 
days was far enough removed to allow the scientific mind to grope 
its way to higher ground. It was not, perhaps, until the eighteenth 
century, that this air we breathe, and which for centuries the sick had 
been denied, save in a more or less poisonous state, began to be 
intelligently considered, and ventilation began to be the cry. 

It is thus apparent that it was not until men became free to inves- 
tigate, and science, born, it may be, under the stimulating hope of a 
better life, came with religion to bless our race, that improvements 
in the construction of hospitals took intelligent shapes, and buildings 
intended for the care of the sick ceased to be grand palatial struc- 
tures erected for their death. 

Let us go back a little, to see how the soldier and the sailor fared 
during all these years of Christian influence. In the wars under the 
Cross and against the Crescent, the hospitals of the Church were of 
course open alike to civilians, soldiers and sailors. These wars 
stimulated in an unexpected manner the erection of retreats for the 
sick ; for, as a result of the Crusades, establishments for lepers had 
to be erected all over Europe, and great numbers of them were built 
even in England and Scotland. 

When Christian nations themselves appealed to the sword, the 
wounded were in great part distributed in the nearest towns and 
quartered upon the inhabitants. In this we see a repetition of the 
practice of pagan peoples. It is true that in some Christian countries, 
the State insisted that the hospitals of the Church should receive the 
wounded, but it is fair to say that military and naval hospitals have 
never originated from a spirit of humanity, but have been born of 
sheer necessity, and from the spirit of science in war. 

It seems that the first record of a separate hospital for the wounded 
erected by a Christian government bears the date of 1575, when, 
under the immediate influence of Ambrose Par6, and the general 
influence of writers on military science at that time, a military hos- 
pital was built at the siege of Metz. 

In 1666, when Colbert, that wise minister of Louis XIV, founded 
Rochefort and organized the navy of France, necessity created a 



220 GATEWOOD. 

naval hospital in the little priory of Saint-l^loy. Thus, amidst the 
sick and dyings in the swampy grounds of the new station, France 
began the lesson which her many naval hospitals show that she 
learned so well. 

In 1694, the partially erected palace at Greenwich, England, was 
converted into a residence for worn-out and wounded seamen. In 
the tax for the maintenance of that hospital can be found the sug- 
gestion to the American colonies, which eventuated in the establish- 
ment of our own marine hospital service and our own naval hos- 
pitals. 

It was not until 1756 that the modern ideas of hospital construc- 
tion found anything like an intelligent expression — when a London 
architect, named Roverhead, designed a naval hospital which was 
built at Stonehouse, near Plymouth, England. The design was a 
compromise between the old block system &nd the present one of 
sepirate buildings. This hospital, with its ten detached buildings, 
began a new era in hospital construction just seven centuries after the 
erection of the first general hospital in England. 

Since the founding of Rochefort by Louis XIV, since the conver- 
sion of the palace of Charles II into a harbor of refuge for the 
disabled warriors of the sea, naval hospitals have sprung up along 
the coasts of all civilized nations. Born of no religion, the offspring 
of sheer necessity, they wait for the tocsin of war. As quiet as the 
smile of peace on the face of Europe, their polished wards for the 
most part silent and unused, they stand amid trees and flowers, a 
ready refuge for the heroic lovers of country and of home, or for the 
victims of ambition, greed or revenge. They stand on sure founda- 
tions, and their walb will never crumble until the day of everlasting 

peace. 

Naval Hospitals. 

These institutions are not special hospitals, but general hospitals 
for the treatment of a special class. They present marked peculiar- 
ities, which differentiate then froni civil establishments. They are 
situated, as a rule, near navy-yards, that they may be accessible to 
the sick of the station and of the various ships, and are surrounded 
by several acres of ground containing trees, shrubbery, flowers and 
lawns. The number of patients is liable to very great variations, 
depending upon the movements of the different squadrons and the 
varying exigencies of the service. The medical officers are all resi- 
dent, and have no duty to perform outside of the institution. There 



NOTES ON NAVAL HOSPITALS. 221 

are no visiting physicians and surgeons, and consequently no unpaid 
medical talent. 

When a patient is received he has already been under the care 
of a medical officer, and is accompanied by a hospital ticket stating 
the diagnosis and history of his case. All the patients are practi- 
cally under absolute control, and have their movements and dates of 
discharge determined for them. The sick are of different ranks and 
grades, thus requiring more or less segregation, and necessitating 
additional expense to the government, without increased compensa- 
tion. The sick must be kept until they are fit for service at sea, or 
for discharge from the navy. This leads to a much lower general 
intensity of disease than exists in civil hospitals, and to a large 
number of convalescents and semi-convalescents who may perform 
light work about the building. 

All the naval hospitals of one nation are conducted under the same 
rules and regulations; and to guard against improper claims for 
pensions, much work is done on Boards of Survey, and in making 
out papers and writing journals. 

The fact that all the medical officers are permanent members of a 
corps including different ranks, requiring good records for promo- 
tions, and necessitating a life under navy regulations, leads to more 
caution, and, may be, to less independent action; and while it throws 
an increased responsibility upon the medical officer in charge, it 
tends, perhaps, to diminish the originality and ambition of the juniors. 

Naval Hospitals of England. 

The English navy has 711 ships, 58,142 men and 13 hospitals. 
These hospitals contain 3617 beds, and have daily under treatment 
about 1 100 patients. The sick berth-staff on shore numbers 230, 
and is maintained at an annual expenditure of $65,000. At the head 
of the medical department is the Medical Director-General at the 
Admiralty. 

The following titles designate the various ranks included in the 
corps : Deputy Inspector-General of Hospitals and Fleets, ranking 
as rear-admiral (does not serve at sea in time of peace) ; Deputy 
Inspector- General of Hospitals and Fleets, ranking as post-captain 
(does not serve at sea in time of peace) ; Fleet Surgeon, ranking as 
commander ; Staff Surgeon, ranking as lieutenant of eight years 
service; and Surgeon, ranking as lieutenant under eight years 
service. 



GATEWOOD. 



Candidates for admission to the Medical Corps enter an open com- 
petition before a specially selected board that sits in London. When 
successful, the candidate is ordered at once to Haslar for special 
instruction. The hospitals are situated at Haslar, Plymouth, Chat- 
ham, Haulbowline, Great Yarmouth (lunatic asylum), Malta, Ber- 
muda, Jamaica, Ascension, Cape of Good Hope, Hong Kong, Yoko- 
hama, and Esquimau. 

It is believed that a study of most of these, and of the Medical 
School and Training School for Nurses, will furnish some desirable 
information. 

The Royal Naval Hospital ai Haslar. 

At this hospital, which is on the water's side, close to Gosport, in 
view of Spithead, and about a mile and a half from the town of 
Portsmouth, b concentrated much of the activity of the Naval Medi- 
cal Service on shore. This one institution comprises not only a large 
hospital, but also the Naval Medical School, the Training School for 
the Nursing Staff of the service afloat, and ashore, and a depot of 
medical supplies for the various ships and stations. 

The buildings (52 feet high)areofthreestories, made of brick, sup- 
plied with many ot the modern improvements and conveniences, and 
arranged around three sides of a square in two rows, one within the 
other, leaving the rather narrow space between of 35 feet Around 
the inner row on the ground floor is a corridor, which thus borders 
the large enclosed area, and furnishes an outside means of commu- 
nication. The fourth side of the square, 400 feet long, is partially 
occupied by the chapel, which faces the middle or executive part of 
the building (Fig. i). 




Fig. I. Naval Hospital, Haslar. F, Front. 



The wards (60X24 feet), which are divided into medical and surgi- 
cal, are, as a rule, supplied with open fireplaces, and with windows 
on both opposite sides. They are thus fairly well ventilated, but are 



NOTES ON NAVAL HOSPITALS. 22$ 

rather too wide for their length, and the ceilings (lo and I3 feet) are 
too low. They contain as a rule about fourteen beds, and give an 
average of iioo cubic feet of air space and 103 feet of floor space to 
each bed. The walls are colored plaster, and the floors ordinary 
deal, but some of the surgical wards have teak floors laid in cement. 
The polish of these, under an application of beeswax and turpentine, 
adds to the appearance of cleanliness visible everywhere. 

The plan of this hospital is a singular one, and presents in more 
than the usual degree all the grave objections inseparable from the 
block system. This establishment was built in 1762, at a time when 
ventilation was being considerably discussed. It is fair to presume 
that economy prevailed, as well as a tendency to cleave to old tra- 
ditions. 

The grounds in which this building stands extend over 60 acres. 
They are beautified with lawns, trees, shrubbery and flowers. Some 
of this could very well have been devoted to more groimd space in 
construction, lessening the number of floors, and separating and in- 
creasing the number of buildings. However, this hospital has been 
continuously occupied for more than a century, and the mortality 
rate is small even now. This b doubtless due in part to the superior 
administration incident to it as a government institution, and to the 
number of patients being as a rule much below the capacity. This 
latter enables the wards to be more frequently renovated, and allows 
an additional air space. 

This immense hospital has accommodation for 1298 patients, 
including 68 sick ofiicers ; but the average number under treatment is 
somewhat less than 500. The stafl* consists of seven medical oflicers, 
including an inspector-general, who is in charge. There are several 
large residences in the grounds near the hospital for most of these, 
while others are accommodated within the building. The stafl* seems 
small when one considers the large amount of work in the hospital 
and schools. There can be but little time for more than the very 
closest attention to duties. 

An interesting portion of the Haslar hospital is its kitchen, which is 
situated on the top floor. It is connected with the wards by eleva- 
tors, which enable the food to be conveniently distributed. But little 
coal is used in this kitchen. Steam is used to do all the boiling, and 
broiling is done by gas heat. The crockery upon which the meal is 
to be served is kept hot on iron tables heated by steam. One can 
see that this arrangement must be very satisfactory for several reasons, 



224 GATEWOOD. 

not the least of which is the absence from the wards of the kitchen 
odor. 

The surgical cases in this hospital are about four times the medical. 
About one-half of them are venereal cases, which cause the largest 
amount of invaliding. Several hundred wounds are treated annually, 
with a very small mortality and a reasonable percentage of invaliding. 

The medical cases average about loooa year; the principal dis- 
eases being rheumatism and pneumonic phthisis. The latter is the 
most frequent cause of death and invaliding. Many cases of remit- 
tent fever reach this hospital, chiefly from the Mediterranean Squad- 
ron. A large proportion of the sick from that and the home squadron 
is received, as well as all the sick from the neighboring dockyard. 

A short time ago there was no separate building for contagious 
diseases, and all such cases were treated in one of the end wards. 
Possibly, this very unsatisfactory arrangement has been changed. 
The laundry is in a separate building, and is supplied with modern 
improvements. 

The storehouse is also separate, and it is large, as it is here that 
many medical supplies are kept for distribution to the various ships 
and stations. In connection with this work there is a permanent 
board, consisting of the senior medical officer and others from the 
hospital staff, for examining and inventing improvements in naval 
medical appliances. The method of packing and transporting medi- 
cal and surgical outfits in expeditions on shore, appliances for 
moving the wounded in battle, improvements in operating cases, 
medicine chests, ventilating apparatus, water filters and the like, 
receive special attention in the effort to keep the service supplied 
with all possible improvements. As soon as anything is approved 
it is sent to one or more ships in actual service for the only true test 
of merit. 

The Naval Medical School. 

The Naval Medical School is for the purpose of giving the medical 
officers recently admitted to the service, instruction in hygiene, 
military medicine and surgery, pathology, and all subjects necessary 
for the most efficient performance of those special duties created by 
naval life. Instruction was formerly given at Netley, but, in 1880, 
the Naval School was removed to Haslar. 

The reasons for this change were many. The young naval sur- 
geon was desirous of learning naval duties, while the army school 
naturally emphasized those pertaining to its own service. Another 



NOTES ON NAVAL HOSPITALS. 22$ 

consideration, probably more potent, was that nothing stimulates a 
corps and develops its talents so much as a school taught by itself. 

In teaching a class formed of recent graduates in medicine who 
have built upon a good general education, the older members of the 
corps are stimulated to greater activity, and a new force is introduced 
to prevent that stagnation to which there is such a marked tendency. 
Haslar, with its larger number of cases, many representing diseases 
incident to naval service, and with its proximity to the great naval 
station at Portsmouth, furnished a place pre-eminently calculated to 
facilitate the special instruction desired. Besides, who are so compe- 
tent to teach the requirements of any service as those who are 
familiar with them by long experience? 

As soon as the graduate has passed the required examination for 
entrance, and has received his commission, he is ordered to Haslar 
for this instruction. The course lasts for four months, and though it 
does not establish precedence in the service, this having been pre- 
viously determined, it does determine the degree of adaptability and 
has much to do with the assignment to duty. All the papers and 
marks of the first examination are sent to this school by the Medical 
Director-General of the Navy. These must furnish eventually some 
interesting data bearing upon the competency of any examination to 
determine that essential quality known as adaptability. 

The class, as a rule, consists of about twenty members, more or 
less. Quarters are provided for them in the hospital, two wards 
being fitted up for this purpose. They also have a special dining 
room and a sitting or reception room. A billiard room is also pro- 
vided, and outdoor sports are encouraged. 

The school is well equipped for its special work. The library or 
lecture room is well provided with the best Hterature on medical and 
kindred subjects. The museum, which receives additions from almost 
all the medical officers in the service, is provided with collections of 
materia medica, alimentaria, natural history, pathological and geolog- 
ical specimens, and the appliances used in the service. There are 
also models of ships, and diagrams showing ventilating apparatus in 
use, and proposed. 

The laboratory contains many microscopes and all the apparatus 
necessary for bacteriological research, and the analysis of urine, 
water, soil, food, air, and clothing. 

In the wards of the hospital much instruction is given in minor 
surgery and case-taking. Each member of the class is also made 



226 GATEWOOD. 

thoroughly familiar with the various blank forms used in the service, 
the system of making sanitary reports, and the method of keeping 
medical journals. 

Autopsies are made as opportunities occur, and written reports are 
made of all pathological conditions. 

The work of the day begins in the wards. This is followed by 
work in the laboratory, and by a lecture in the library. This lecture 
is often illustrated by various models and diagrams. In the after- 
noon perhaps the dry dock may be visited, where ships in ordinary 
and in various stages of construction are inspected from a sanitary 
point of view, and a draughtsman explains the plan being followed 
in the construction. 

The final examination is made up of oral and written questions and 
practical work. All written questions have been submitted to the 
Medical Director-General of the Navy. The possible total mark is 
3,000. To the principles of hygiene and practical hygiene are 
assigned 1,000 each, while journal-keeping, pathology, and military 
medicine and surgery absorb the other 1,000. 

This school is so practical in its teaching, so praiseworthy in its 
object, and so far-reaching in its influence that it is well worthy of 
imitation by all nations. 

The Training School for the Nursing Staff. 

This school was established at Haslar shortly after the medical 
school. It was the outcome of a report by a special commission 
made in 1884. The old system of civilian nurses led to the change, 
as the material supplied by this method was very often exceedingly 
poor. Now, nearly all the nurses for the navy afloat and ashore are 
being obtained primarily from the Greenwich Hospital School. 

At that school a fair general education is given, and various 
mechanical trades are taught. After some service at sea, if the boy, 
who is about 17 years old, desires to become a nurse in the navy, he 
makes application, and after a rigid physical examination is received 
at Haslar. Here he finds himself with others quartered in a large 
ward in the third story of the administration building. 

Nine or ten trained female nurses of the highest respectability have 
been procured to facilitate the education, and he is taught by lectures 
and in the wards by seeing the things done that he is to learn to do. 
A certain amount of minor surgery, such as bandaging, is also taught, 
and when the student is considered qualified, he is sent to sea. After 



NOTES ON NAVAL HOSPITALS. 22/ 

a cruise he is eligible, if his record be good, for service in the hos- 
pitals, and can enlist under special regulations providing promotions 
and increased pay. 

The Royal Naval Hospital at Plymouth^ 

or rather at Stonehouse, was built in 1764, and is next in import- 
ance to that at Haslar. It consists of ten separate buildings, or 
rather eleven, including the chapel, each constituting a separate hos- 
pital. These surround a large square laid out in grass plots and 
gardens. A colonnade ornamented by one hundred and fifty mono- 
liths connects them, and extends around the sides next the court. 

There are 44 wards. Each ward contains fourteen beds, sepa- 
rated by over five feet. They accommodate six hundred and 
sixteen patients, and give an air space of twelve hundred cubic feet 
to each. The ventilation is good, the buildings are remarkably 
clean, and the absence of hospital odor is noticeable. The plan of 
this hospital permits a free circulation of air within the court, a good 
general ventilation, and a very desirable segregation of patients. 
House cleaning and painting can be carried on with little or no incon- 
venience or annoyance. 

Generally there are six wards in each building in use for the sick. 
Quarters are provided for fifty-one sick officers, and room is given 
for a smoking room and library. The water supply is good, an^ 
there are rooms supplied with hot, cold and vapor baths. The water- 
closets are excellent. 

The plan of this hospital is considered the bestof any of England's 
naval hospitals, and it has frequently served as a model. 

The total capacity of this institution is considered to be six hundred 
and sixty -seven, but in 1780 the remarkable number of fourteen 
hundred and twenty-three were treated here at one time. Probably 
many were placed under canvas. 

It has an easy approach for boats by way of Plymouth Sound, and 
receives sick, not only from the fleets, but also from the dockyard 
and marine barracks. 

The total number of admissions each year approaches thirty-five 
hundred. The surgical wards receive about twice as many as the 
medical. The average number daily under treatment is about three 
hundred. 

In the medical wards rheumatism and pneumonic phthisis are the 
principal diseases, the latter being the chief cause of death. In the 



228 GATEWOOD. 

surgical wards, venereal troubles are in the large majority, these 
amounting in a year to about one thousand. Syphilitic and gonor- 
rhoeal troubles divide the honors. About two hundred cases of 
injury are treated annually. The loss by death is small, but the 
invaliding is not inconsiderable. 

There are over fifty in the nursing staff, while the hospital staff 
consists of an inspector-general in charge, a deputy inspector-general, 
two staff surgeons, and three surgeons. The wards are visited four 
times daily or oftener by the surgeon having the day's duty, while 
those in charge of particular wards make routine visits morning and 
evening. A very good library is provided for the medical officers, 
and the seniors have separate residences for themselves and families. 

Royal Naval Hospital (^Lunatic Asylum) at Great Yarmouth. 

Great Britain has made generous provision for the insane of the 
navy. Probably there is no institution better supplied and more 
ably managed than the asylum at Great Yarmouth. 

So desirous is the Admiralty that the guiding shall be by the most 
experienced hands, that there is no rotation of officers assigned to 
this special work, the inspector-general in charge retaining the duty 
permanently. All recommendations made by this officer, who has 
absolute local control, meet with more than the usual compliance, 
^nd all requisitions for supplies are considered in a spirit more than 
usually generous. 

No government can really afford to do otherwise: for nothing 
increases the tendency to cheerful work, or acts so constantly to 
maintain discipline in a service, as the belief on the part of all that 
they will be well cared for in sickness, misfortune, or death. This 
consideration has at times been forced upon the attention of authori- 
ties, and has had much to do with improvements in all services in all 
governments. 

The hospital at Great Yarmouth was built early in this century, 
but was used for a naval hospital only a few years. In days of peace 
it passed into the hands of the army for use as a barrack. However, 
when the century was a little more than threescore years old, it 
became a naval establishment again, and was devoted to the care of 
those wrecked in mind as well as in body — patients living in a realm 
of their own. 

This hospital is another illustration of the block plan, but in this 
case there are four two-story brick pavilions arranged around a 



NOTES ON NAVAL HOSPITALS. 229 

square of one and three-quarter acres, with the corners sufficiently 
open to allow the free circulation of air (Plate I). There is an arched 
corridor eight feet wide around the lower inner face of each build- 
ing, and forming their only connection. This plan or arrangement 
is considered one of the best of any of the older hospitals in the 
United Kingdom, and though the situation is rather bleak, the 
selection of this hospital for the present duty is regarded as most 
wise. 

Each pavilion is two hundred and sixty feet long, and, with the 
exception of the one in front, is divided into two sections by a cen- 
tral structure unoccupied by beds. These sections are subdivided 
by staircase and nurses' rooms. This results in the formation of 
eight well separated wards in the pavilion. However, the wards on 
the lower floor of the rear pavilion have been divided into rooms 
opening on the corridor, for the use of those too restless to occupy 
beds near others. 

The wards are forty feet long, twenty-three wide, and fourteen and 
a half high. They have windows on both opposite sides, with beds 
between. They were originally designed to be occupied by fourteen 
persons, but the number under treatment is so very much less than 
the capacity that this overcrowding is made impossible. Indeed, the 
space unoccupied by beds is so great that it is used for several din- 
ing rooms and day wards. 

The water-closets are in small towers outside of the line of the 
wall, and the connections have lattice-work sides, to allow the air to 
sweep through. The bathing facilities are ample, and include even 
a Russian bath. This part of the building is not for show, but is used 
regularly and systematically under the rules of management. 

The front pavilion has the second story divided into rooms for the 
officers under treatment. There is a dining room in connection with 
these, while a very large parlor on the first floor is set apart for the 
reception of friends. This lower floor is used, however, chiefly for 
administration purposes. All the buildings are heated by hot water 
pipes, and to a certain extent by open fireplaces. 

The position of the nurse rooms between wards facilitates their 
work very much, as, with a suitable division of patients, two wards 
can often be watched at night by one nurse. 

Wherever practicable, a certain amount of ornamentation is used 
to give as homelike an appearance as possible, and even curtains 
have not been discarded. This is probably more or less wise as a 
part of the treatment. 



230 GATEWOOD. 

Regulations are strictly enforced in regard to a frequent change of 
bedding. This change is made immediately when needed in cases 
confined to bed. Close-stools are cleansed at once, night and day, 
and frequent visits are made to the restless ones in the separate 
rooms. There are padded rooms in this institution, but the idea 
governing the treatment leads to only an occasional use of them. 

There is one nurse for eight patients. This does not seem a large 
allowance. Yet much work is done by the patients themselves. 
Such occupation is considered a valuable part of the treatment in 
many cases. It keeps the mind from (as it were) feeding upon itself, 
and, in the accomplishment of something that can be seen, tends to 
bring back the interest in life. Trades are encouraged, and places 
are provided for the pursuit of such pleasant occupations. The 
nurses are carefully selected, and can be instantly discharged for 
incompetency or carelessness. 

This institution is surrounded by more than nine acres of ground, 
some of which is divided by walls into exercising courts. Arbors 
and covered ways have been built for use in bad weather. The 
outdoor plan of treatment is pursued here whenever advisable, as it 
often is, and every attempt is made to take away from the mind the 
idea of prison life. 

The kitchen is in a detached building, and is well equipped and 
managed. The laundry, which is near it, is kept as busy as all such 
should be. Comfortable houses are in the fore-court of the hospital 
for the two medical officers comprising the staff. At present there 
are about one hundred and fifty patients, including forty officers, 
more or less. 

The mortality averages ten per cent, and the recoveries are 
relatively many. Mania designates more than one-half the cases ; 
and dementia, melancholia, and paralysis of the insane, follow in the 
order named. The admissions are sufficient to keep the total number 
under treatment about the same. 

Royal Naval Hospital at Malta. 

This hospital is situated near the walled city of Valetta, on the 
north side of the island of Malta, in the Mediterranean Sea. Malta is 
a sand and limestone formation, eighteen miles long and eight wide, 
with its long axis approximately northwest and southeast. A range 
of hills forms its backbone. It is from these that an ancient and 
leaking aqueduct conveys a limited supply of good water into 



NOTES ON NAVAL HOSPITALS. 



231 



Valetta. Cisterns are used for storing this and rain-water ; but as 
these are often polluted by leaks, intestinal disorders and typhoid 
fever are not uncommon. 

The climate is very delightful from October to April, the thermo- 
meter ranging from 50° F. to 70° ; the atmosphere, under the north 
winds, fairly dry, and the days almost invariably full of sunshine. 
This enables invalids and convalescents to live out-of-doors. During 
this period the rainfall is over twenty inches, but, most conveniently, 
it falls as a rule during the night, and upon a soil that drains rapidly. 
Snow is unknown, and the formation of ice is a surprise. 

The beat during the summer makes sunstroke not infrequent, 
while in early autumn the moist sirocco or southeast wind debili- 
tates mind and body, and predisposes to neuralgia and malarial 



Valetta is a terraced city, on the end of a high tongue of land that 
makes out to the northeast within one of the many indentations of the 
coast Its end, however, St. Elmo Point, is so far out as to be on 
the general coast-line, and forms with Ricasoli Point the entrance to 
the harbor or bay which is southeast of the city. 

Across this bay, half a mile from the city, and on a bold promon- 
tory between Forts Ricasoli and St. Angelo, is tlie largest foreign 
naval hospital of Great Britain. It has a beautiful site, overlooking 
the city and harbor, and its Doric two-story stone buildings present 
an imposing appearance. 




Fic. i. Naval Ho! 

IV. Wings. C. Court. //. Inspector's House 



2^2 CiATEWOOD. 

The building that fonns the front looks to the northwest, and the 
detached building oti each side extends back perpendicular to the 
line of the main structure. There is a corridor around the inner face 
of each, and the enclosed court, which covers an immense cistern, is 
paved. 

The wards are nearly one hundred feet long, twenly-five wide and 
twenty-two high. There are, however, smaller wards, and many 
rooms for sick officers. They furnish nearly 1800 cubic feel air space 
per bed. and are supplied with a fair number of high windows, open 
fireplaces, and large openings near the ceilings. The ward furniture 
is reduced to a minimum. The beds are iron, and the mattresses 
always look new, as they are frequently re-made. There is a good 
smoking-room and a library. 

The bath-rooms are supplied with modern improvements, and the 
waler-ciosets, though near the wards, are well supplied with seats 
and water and are easily flushed. The floors of these, being tiled, 
are easily kept dean and present a good appearance. A small build- 
ing about three hundred yards from the main buildings, is used for 
contagious diseases. There is also a large storehouse, which is kept 
well filled with medical supplies for the fleet. 

The nursing staff consists often, and these are fairly well provided 
with quarters. The kitchen and laundry are on the ground floor. The 
medical inspector in charge has a large residence east of the build- 
ings. This hospital has accommodations for two hundred and eighty 
patients, including fifty-eight sick officers. 

The wards are divided into medical and surgical, and the average 
number under treatment is about eighty. The number treated 
annually approximates one thousand — about equally divided between 
medical and surgical cases. The number of cases of remittent fever 
treated annually often approaches one hundred ; about fifty per 
cent of these are eventually sent home to recover from the conse- 
quent debility. Typhoid fever is not uncommon, there being, per- 
haps, fifteen or twenty cases each year, with a mortality, it seems, of 
about twelve per cent. The general death-rate of this hospital is not 
very large, but a considerable number of invalids are sent home by 
the troop-ships to escape the summer and early fall, 

The authorities of this port are exceedingly sensitive on the subject 
of epidemic influences, and as a result the quarantine regulations are 
very rigid. The large number of troops in the garrison, and the 
importance of the island as a naval station and base of operations, 



NOTES ON NAVAL HOSPITALS. 233 

necessitate, however, the greatest caution. There have been sad 
experiences with cholera, which is the disease most dreaded, as the 
island is on the line of travel from the East. 

The Royal Naval Hospitals at Bermuda, Jamaica, Ascension, Cape 

of Good Hope^ and Esquimalt. 

These hospitals present nothing especially worthy of attention. 
They are, of course, of inestimable importance to the naval service, 
and from that point of view demand some notice. It is believed 
that the following short notes will be considered sufficient : 

Bermuda, — The hospital is situated on Ireland Island, the naval 
station, and occupies rather high ground, overlooking the water to 
the west. It is three stories high, and contains four wards, two on 
the second and two on the third floor. These wards are thirteen feet 
high, twenty-four feet wide, and sixty long. They contain fifteen 
beds each, and furnish a little more than twelve hundred cubic feet 
per bed. Considering the climate, this space should be at least 
doubled. Ordinarily this is the case, as the average daily number 
under treatment in time of peace is only thirty, including sick 
officers, who have rooms on the first floor and are provided with a 
private dining-room and library. 

The whole building is entirely surrounded by broad verandas, 
which are necessarily supplied with Venetian blinds. There are 
water-closets and bath-rooms on each floor. As the ground furnishes 
a rather steep slope the drainage is good. Innumerable gutters 
conduct off" the surface water, while the water-closets have a sewer 
leading out into the bay. 

The kitchen and laundry are in a small detached building ; but, 
unless there has been a recent change, meals are served on small 
tables in the wards for lack of space for a messroom. It is needless 
to criticise this undesirable condition of things. 

There is no separate building for contagious diseases. Suspicious 
cases are allowed to develop in the hospital, and then, if necessary, 
are transferred to the common pest-house on the island. The water 
supply is rain-water collected in cisterns. 

The deputy inspector in charge has a separate house. He and 
two surgeons comprise the staff". The number of nurses allowed is 
four. The total number of cases treated annually is about two hun- 
dred and fifty. The number of surgical cases is double that of the 
medical. Venereal troubles form about twenty percent of the total. 



234 GATEWOOD. 

Remittent and typhoid fevers are rather frequent. The average 
number of days under treatment per case of all diseases is nearly 
fifty. 

The climate of the Bermudas is exceedingly pleasant and equable 
in winter, but in spring, summer and fall the heat is frequently 
oppressive, though much modified by breezes. The average tem- 
perature during this period is about 77 degrees F. 

Jamaica, — At Port Royal, the naval hospital is an extensive build- 
ing, but only a part of it is kept in operation or in fair condition. 
In the early part of this century, events seemed to necessitate a large 
building for the sick in this part of the world. Its capacity is now 
considered to be one hundred and twelve, including rooms for twelve 
sick officers ; but the average number of cases daily under treatment 
is only ten. Five nurses are allowed, as the intensity of disease is 
liable to sudden changes in this climate. In 1882, forty cases of 
yellow fever were treated in this hospital. 

In the event of any increase of the naval force in these waters, or 
even of any interference with the cruise to the north in summer, the 
number of cases and the intensity of the disease would be much 
increased in this building. As it is, the total number of patients 
during a year is usually only one hundred and fifty, the medical 
rather exceeding the surgical cases. About eight percent are 
invalided, and the loss by death frequently approaches the rather 
large number of fifty per thousand. This mortality is due in great 
measure to fevers of various types. Venereal cases number fifteen 
or twenty annually. 

Three medical officers compose the staff. These, in addition to 
usual duties, have charge of the large amount of medical supplies 
kept here for the fleet. 

Yellow fever receives little attention at the quarantine station across 
the bay, but smallpox is regarded as the great enemy, demanding 
constant watchfulness. 

Ascension, — This building is in Georgetown, a very small naval 
settlement on the west coast of Ascension Island. This volcanic 
island has a diameter of six miles. Its surface consists of many hills 
and mountains, intersected by innumerable watercourses and deep 
valleys. The mountains frequently attain an elevation of fifteen hun- 
dred feet. Much of the coast is formed of rough lava rocks, while 
the hills and mountains present many well-formed craters. 

The hospital is at the extreme south of the settlement, high above 



NOTES ON NAVAL HOSPITALS. 235 

the water, from which it is distant a fraction of a mile. It has accom- 
modations for sixty- five sick, including fourteen officers. There is 
only one nurse allowed, but the average number of patients daily is 
but six. About one hundred cases are treated annually. The medi- 
cal cases are about double the surgical. 

As might be expected, venereal troubles are rare, and malarial 
fevers are very common. These latter are brought by the ships 
cruising in the rivers and on the coast of West Africa. Indeed, this 
island is used as a sanitarium. Vessels are sometimes almost entirely 
deserted, and the crews placed in the barracks on Green Mountain, 
near the center of the island. From near this mountain, water of 
good quality is supplied to Georgetown. 

At this hospital the mortality is frequently only about ten per 
thousand; the invaliding, ten percent; and the average number of 
days treatment per case, less than twenty-five. 

Cape of Good Hope. — The naval hospital here is small. There are 
accommodations for eighty patients, including rooms for six sick 
officers. The average number of patients daily under treatment is 
twenty-five, and the total yearly is three hundred. The surgical 
cases are three times the medical. This is to be expected, as venereal 
troubles are common. 

Ships cruising in these waters have few places where liberty can be 
given. Cape Colony is one of these. About one hundred venereal 
cases find their way to hospital in the course of a year. Of course, 
this is a small proportion of the total number of cases. 

Ships cruising on the West Coast bring, from time to time, large 
numbers of malarial cases to this hospital. The death-rate is rela- 
tively small, but the invaliding is over eighty per thousand. Summer 
is the most healthy season, as it is then that the southeast winds 
prevail. 

Esquimau, — This is the smallest of all the royal naval hospitals. 
It can accommodate but forty patients. The average number daily 
under treatment is only five, and the total number yearly, less than 
fifty. Only one or two are invalided during the year, but the aver- 
age number of days treatment per case is generally over forty. The 
building is wooden, well-lighted, but poorly ventilated, with two 
wards. It has ten acres of ground on the west coast and south side 
' of Vancouver Island, and overlooks Constance Cove, a part of 
Esquimau harbor. 

The surgeon has a house about thirty yards from the main build- 



i 



•I 

f. 

f° 

-i 
i, 

Vr 
■| 



236 GATEWOOD. 

ing. In this there are also rooms for four sick officers. There is a 
structure for contagious diseases. 

Across the Cove and distant a small fraction of a mile is the dock- 
yard. This is the British naval station in the Pacific. 



■ Royal Naval Hospital at Hong Kong, 

r This hospital is situated in the eastern suburb of the city of Vic- 

toria, on the island of Hong Kong. This island, which is just 
^- within the tropics (latitude 22® north, longitude 114° east), is eight 

; miles long and averages about three miles in width. The long axis 

is nearly on the parallel. A great part of the surface is formed by 
barren mountains of volcanic rock which rise in many places over 
fifteen hundred feet, and are swept during the winter months by the 
northwest monsoon, and in the summer by the southwest. 

The north wind sometimes in January forces the thermometer at 
Victoria down to 40** F., when snow may appear on the mountain 
tops. The mean annual temperature of the city is 73** F. The 
hottest month is July, when with a mean temperature of 86^ F. and 
with a humidity of t^n grains per cubic foot, sunstrokes are not 
uncommon. The coldest month is January, with a mean of 52® F. 
and a humidity of four grains per cubic foot. The highest barometer 
is in November and the lowest in July. 
\ The wet months are June and July, and the dry months, January 

; and February. The rainfall averages eighty inches, and the rainy 

i days over one hundred. 

.1 

I Victoria, which is on the north side of the island, and one mile from 

the mainland, has a population of over two hundred and twenty 

I thousand, including two thousand Europeans and Americans. The 

English rule is strict, so that in spite of the large number of Chinese, 
cleanliness is observed and epidemics are rare. 

The houses are built upon volcanic rock or its derivative laterite, 
which retains the water during the wet and hot months, and increases 
the marked tendency to malarial troubles. Turning up the soil is 
dangerous on that account, but the English authorities have done 
much, by paving and other sanitary precautions, to improve the 
general health. Dysentery and diarrhoea have become less common, 
but smallpox, on account of inoculations, still clings to the Chinese 
homes. 

In the eastern suburb of the city is situated the Royal Naval Hos- 
pital, two hundred feet above high water, and overlooking the city 



NOTES ON NAVAL HOSPITALS. 237 

and harbor. It is a fraction of a mile from the coast-line and dock- 
yard. 

The hospital was a private residence, and was bought by the gov- 
ernment for £^000. It consists of four buildings, each thirty feet 
square, built of stone, two stories high, and shaded by verandas. 
The enclosed square, which receives the breeze through the space 
between the buildings, is paved. The water-closets and bath-rooms 
of each building are separated from the wards and placed in offsets. 

The upper stories are the four wards, each containing twelve beds, 
and furnishing thirteen hundred cubic feet to each bed. These wards 
have high ceilings, windows on both opposite sides, and are lighted 
by gas. In the lower stories are storerooms, dispensary, nurses* and 
officers* quarters. The Deputy Inspector in charge has a good 
residence. He and two surgeons comprise the staff. 

The water supply is derived from mountain streams and reservoirs. 
Provision is also made for the dry season by storing in tanks. The 
English authorities have done much to protect the water from pollu- 
tion, and have succeeded in increasing its reputation for being the 
best on the coast. 

The hospital has accommodation for fifty-six patients, including 
eight officers. During the year, about three hundred patients are 
treated — the surgical being only slightly greater than the medical. 
The cases of venereal diseases average about fifty annually. Dysen- 
tery, smallpox, and remittent and typhoid fevers are not uncommon. 
Occasionally cholera claims a victim. The number of cases invalided, 
averaging about eight per cent, is chiefly from the medical wards. 
The death-rate sometimes does not exceed one per cent of the total 
humber treated. In the early spring many patients go with the fleet 
to Yokohama, as the moist summer heat materially delays conva- 
lescence. 

Royal Naval Sick Quarters at Yokohama, 

This hospital, which was formerly a barrack for English troops, is 
a plaster and tile building of one story, built on three sides of a 
rectangle (Plate II). It is situated on a bluff which rises from the sea 
to the height of one hundred and twenty-five feet. The trend of the 
coast here is toward the northwest. As the building faces the east, 
and the sea from which the prevailing winds come, the enclosed 
court is shut off from the breeze. The length of the front is about 
one hundred and twenty-five feet, while that of the wings which 



238 GATEWOOD. 

extend back at right angles is more than two hundred. Around the 
inner face of the entire building there is a veranda which is much 
used in warm weather, and furnishes an outside communication. 

This main structure can accommodate over eighty patients. The 
front and north wings are divided into four wards, each about sixty 
feet long. These wards have windows on both opposite sides, and 
have additional ventilation through openings near the ceiling, which 
discharge near the roof into the air. All these wards are for the 
treatment of seamen and marines. The south wing is divided into 
rooms for non-commissioned and warrant officers. 

The average cubic space per bed is nearly 1500 feet. The build- 
ing is heated by stoves and open fireplaces, the latter, of course, 
assisting much in the ventilation. 

The grounds comprise about five acres, ornamented by grass 
slopes, lawns, groves of trees, and flowers. The locality is a desir- 
able one, and it is on this bluff that most of the foreign residents 
live, and the United States has established its hospital. 

The dispensary and stewards' quarters are two buildings outside 
of the quadrangle, but facing the unoccupied side. To the south of 
these, and on the other side of the main gate, are the dwellings for 
the two medical officers comprising the staff. These houses have a 
detached kitchen and servants' quarters. 

South of the main building, and separated from it by about 
seventy-five feet of lawn, are the quarters for sick officers. These 
consist of rooms well fitted up, and usually more than one room is 
assigned to each invalid. 

The mortuary is at the extreme north end of the grounds, and is 
about 50 yards distant from the main building, from which it is 
hidden by a grove of trees. 

At the extreme southwest corner of the grounds are two separated 
buildings for the treatment of contagious diseases. Near-by is a 
spring, a storehouse and a disinfecting chamber. This part of the 
ground is cut off by a grove of trees. A fire-engine house is near 
the north wing of the hospital. 

The nursing staff consists of seven. These are quartered in a 
building near the general kitchen, storehouse and coal shed, at the 
northwest border of the grounds, and distant from the main build- 
ing about thirty feet. 

The method of dealing with the water-closets is one common in 
the Elast. They can, almost all, be reached from the outside of the 



NOTES ON NAVAL HOSPITALS. 239 

building, and natives, under contract, remove every night the large 
earthen jars. 

The water supply is from wells, a spring, and a tank in which rain 
water is stored. All the drinking water is filtered, and in the summer 
is also boiled. 

The total capacity of this hospital is ninety-five (95), including 
accommodations for thirteen sick officers. The average number 
under treatment approaches thirty (30). The surgical cases are 
nearly double the medical. The death-rate is relatively small, and 
the invaliding, which is influenced by the patients received from the 
hospital at Hong Kong, amounts to about five per cent. The total 
number of patients treated annually is about two hundred. Phthisis 
is common, and the number of venereal cases possibly reaches fifty 
— ^twenty-five percent of the total. Malarial fever and occasional 
cases of smallpox help to make up the record. 

The record of this hospital is influenced by the practice of the fleet 
to cruise north from Hong Kong in the spring. The ships arrive at 
Yokohama j^bout April, bringing all patients from the Hong Kong 
hospital who can be safely moved. They return to the coast of 
* China in the fall and carry back with them all who in the interven- 
ing months promise to be ready for duty, or who would be benefited 
by the change. These transfers, however, are chiefly due to the 
relaxing and debilitating summer at Victoria. 

Naval Hospitals of France. 

The French navy has 378 ships, 75,915 men and 5 hospitals. 

The following titles designate the various grades in the medical 
corps : Inspecteur g6n6ral, directeur du service de sant^, inspecteur 
adjoint, m6decin-en-chef, m^decin professeur, m6decin principal, 
m^decin de premiere classe, and m6decin de seconde classe. 

Each member of the medical corps has obtained his professional 
education at one of the three naval medical schools at Rochefort, 
Toulon, and Brest. 

The hospitals are situated at Rochefort, Cherbourg, Brest, Toulon, 
and Saint Mandrier, and offer with the medical schools no uninter- 
esting study. 

Naval Hospital at Rochejort, Fraiice, 

At Rochefort, on the Charente river, the French made the begin- 
ning of a regular organized navy. Here in 1666 Louis XIV, under 



240 GATEWOOD. 

the influence of his able minister, Colbert, devoted some of his easily 
squandered money to the praiseworthy object of founding a naval 
station. However well chosen the site was from a na\'al point of 
view, from that of a sanitarian it was most unfortunate. The work 
was carried on at the frightful cost of many lives. The swampy 
ground, when turned up, engendered intense malarial disorders, 
making a hospital an early necessity. This was established in tbe 
old priory of Saint- Eloy at Tonnay (Charente). 

Happily there was a village fortunately situated, and abundantly 
supplied with good water. The old priory was soon insufficient, but 
it was not until 1683 tliat the hospital at the new naval station was 
completed. At that date Tonnay Charente was abandoned and tbe 
sick were removed to Rochefort. This new hospital consisted 
originally of eight wards, each containing fifty beds. These were 
placed in two buildings, connected by a central structure for admin- 
istration, two wards on the ground floor of each and two on the floor 
above. The beds were of wood, and each constructed for two occu- 
pants. They were also supplied with green serge cui^tains. There 
was additional room in each building for 40 couches — thus making 
the total capacity 480. 

In a short time, however, in spite of the large mortality brought 
about by the terrible crowding, there was not room for the many 
demanding admission, and, fortunately, tents had to be used. At 
one time there were as many as 700 patients. This occurred during^ 
the frightful epidemics in the navy during the ten years prior to 1750. 
It was in this latter year that an addition was made in the form of a 
new pavilion. 

It seems that the large mortality and overcrowding continuing, 
plans for a new hospital were devised in 1782, and extensive grounds 
were bought in a more elevated situation outside the ramparts. Here 
work was begun in 1783 on a hospital to cos 400,000 francs, and to 
contain 1002 single beds, with 1400 cubic feet of air to each. 

In the middle of 1787 the work had progressed so far that these 
beds were moved in. Iron beds they were, the first used in French 
hospitals. In 1788 this hospital, the present one (Plate III), was 
opened with much ceremony, and in three days the old one was 
abandoned, one may suppose with a sigh of relief; for during the 
105 years it had been occupied, 30,000 dead had been carried out of 
its doors. 



NOTES ON NAVAL HOSPITALS. 24 1 

Naval Hospital at Toulon. 

In writing of the naval hospital at Toulon, one feels that the task 
is more or less disagreeable. The French Government should have 
destroyed it long ago. It was never suitable for a hospital, and yet 
it has been used as such for more than a century. 

In much less time, even the best-planned hospital is in danger of 
suffering from hospitalism ; but an old seminary, wretchedly designed, 
shut off from sunlight and pure air, when used for the treatment of 
the sick, soon becomes contaminated, and each patient entering its 
doors encounters a new danger, in spite of the best directed and 
most skillful efforts of those having him in charge. 

The walls of this institution have been standing since 1686, at which 
time the Jesuits began the education here of chaplains for the navy. 
A similar enterprise had been initiated the year before at Rochefort. 
The government, at such an early date, considered it advisable for 
priests serving in the navy to have special training. 

Twenty-three years after this, by the effort of that memorable 
medical officer, M. Dupuy, a like conviction was instilled into the 
mind of the king's minister, in regard to the medical officers of the 
service, and, in 1725, a school was established at Toulon for a like 
purpose, six years after a similar one had been founded at Rochefort 
At that time, however, there was no regular constituted naval hos- 
pital at Toulon. The sick of the navy had been treated for some 
years in the arsenal. 

In 1 7 16, this proving inadequate, the system was inaugurated of 
paying a civil hospital for this service. This, for several reasons, 
always proves very unsatisfactory, and, as a result, the project of 
establishing a naval hospital was constantly being discussed. 

Time passed, and Toulon increased in importance as a naval sta- 
tion. Economy still prevailed ; but the need becoming more urgent, 
the king, in 1774, signed the transfer of the house of the Jesuits to 
the medical department of the service. The clergy and the munici- 
pal authorities naturally objected, and their influence was so great 
that the change was delayed. 

In 1783, just after peace with England was signed, the French fleet 
broke its rendezvous at Cadiz, and many of the vessels came into 
the harbor of Toulon, having eleven hundred sick on board. There 
were not accommodations for such a large number, and tents were 
used for this purpose. 



242 GATEWOOD. 

The necessity for a naval hospital was thus greatly emphasized, 
and the long-delayed transfer was made in 1785. The school and 
hospital have worked together in this building ever since. 

The building has a front five stories high, facing the south, and 
occupying the shorter parallel side of a trapezoid ; the wings going 
back on the two adjacent sides, and joining a rear building parallel 
to the front. This rear building is again connected with the front by 
two additional perpendicular wings, thus dividing the enclosed 
ground into three small unequal courts — all the wings, and rear of 
three stories, and the extreme west wing extending beyond the rear 
structure its own length. Some idea of this plan is obtained by 
Plates IV and V. 

A massive structure it appears, set down in a densely populated 
city, and separated by narrow streets from the many neighboring 
buildings. There is a court in the rear, a continuation of the trape- 
zoid, with continuous one-story buildings around it, containing store- 
rooms, attendants* quarters, and the like ; and projecting into it, a 
building for a pharmacy, dissecting room, mortuary, laboratory, and 
other offices. But little air stirs within or without such a hospital, 
and the sunlight shining on its high front reaches but little else. 

There are twelve wards, many of them practically being one, as 
the only separation is an arch. They are one hundred feet long, 
thirty wide and fifteen high. They contain, as a rule, twenty-four 
beds each, between and near six windows on each side. There are 
no additional means for ventilating the fairly great allowance of 
nearly nineteen hundred cubic feet per bed. The floors are tiles laid 
in cement, and the walls are whitewashed. A patient, looking out 
of a window, sees, as a rule, nothing but walls, though he may catch 
a view of the sun for a short while. 

The water-closets are separated from the wards by a narrow pas- 
sage. They have a fairly good upward ventilation, though requiring 
frequent disinfection. The drainage is into open gutters, swept by 
a rapidly moving stream of water. 

The total capacity of this hospital is about three hundred, over 
two hundred and eighty being in wards, and the remaining accom- 
modations, for the officers mainly, being in rooms in the front. These 
rooms are supplied with open fireplaces, and, fronting on the south, 
are more cheerful and comfortable. The greater part of the build- 
ing is, however, heated by stoves. 

It is almost needless to say, that in spite of all the skill practised 



NOTES ON NAVAL HOSPITALS. 243 

within its walls, the mortality is great, and patients admitted with 
slight injuries are liable to develop grave troubles. 

The kitchen, though an excellently managed one, is in the base- 
ment, directly under a ward. The bath-rooms are also in the 
basement, but at a considerable distance from the wards, thoroughly 
equipped, and commanding admiration. The laundry work is done 
at a distance, in large stone basins supplied with water by a natural 
stream. There is every attempt made at cleanliness and comfort. 
The linen is frequently changed, and the beds have each two good 
mattresses on well-made springs. 

The efforts of the staff are worthy, too, of every praise, for they 
fight a good fight against a constant and evfer-present enemy. This 
staff consists of eight officers, including the m6decin-en-chef in charge. 
In addition to other duties, many of these conduct the school. 

The whole work is performed in the most excellent manner. Most 
of the nursing is done by men, but the Sisters have the general super- 
vision of them, as well as the care of special cases. These superin- 
tend also the storerooms, kitchen, linen-room, and the general dis- 
tribution of material. 

The Naval Hospital at Toulon is most ably conducted. It could 
not be otherwise, under men who hold their high position by great 
merit only. But France considers herself too impoverished to 
build another, though she listens to the earnest requests and repre- 
sentations of her well-informed medical officers, and continues to 
expand her wonderful navy and army. 

Naval Hospital ( CUrmoni- Tonn^re) at Brest. 

Prior to 1666, the sick of the navy were treated in the civil hospital 
at Brest. At that date, this hospital was destroyed by fire, and an 
old deserted guard-house was taken for this purpose. The building 
was small, in a bad situation, and soon overcrowded. As a result of 
this unfortunate situation, the government was compelled, in 1684, to 
construct a naval hospital. This hospital contained three hundred 
beds, but was too small to accommodate the large number requiring 
treatment, and an addition was built in 1689. 

In 1776, this first naval hospital at Brest was destroyed by fire, 
and it is stated that convicts there under treatment, and still in chains, 
were burned in their beds. After the fire, there was an immediate 
necessity to find accommodations for the many sick. An old Jesuit 
seminary was taken for this purpose — it then being used as quarters 



244 GATEWOOD. 

for the marine guard. The sick were put in this building, and, in 
time, certain additions were made to it, so that it was able to contain 
five hundred beds. 

This seminary was used as the Naval Hospital at Brest until 1834, 
when the present structure was finished. The corner-stone of the 
present hospital was laid in 1822, by Clermont Tonndre,the Minister 
of Marine, from whom it received its name. The site is the same as 
^hat of the old building burned in 1776. It is an extensive granite 
structure, on a plateau back of the city of Brest, and on the left 
bank of the Penfeld river, commanding a fine view of the city and 
the roads. It has two stories and an attic, and contains 1200 beds. 

It is a pity that this large hospital has such a defective plan 
(Plate VI). Though symmetrically arranged, its wards bear such 
a relation to one another that but little light and air are admitted 
to them. All the wards are parallel, and are connected at one end 
by a corridor, or rather gallery, to which they are all perpendicular. 
From this gallery, or rather in the continuation of the wards into it, 
are the stairs connecting the two stories. The wards are joined in 
the rear, mostly in pairs, by passages in which are the water-closets, 
and from which are back stairs connecting the two stories, and also 
steps leading down into the gardens and courts which the various 
buildings enclose. The whole comprises a series built upon the block 
plan, and containing its worst features. 

Each ward is over 170 feet long, 26 wide and 15 high, containing, 
usually, 50 beds, and furnishing over 1200 cubic feet of air space per 
bed. There are sixteen windows on each opposite side, but no other 
means of ventilation, save the two doors. The next building across 
the court is distant less than fifty feet. The beds are iron, and have 
two mattresses on springs. Strange to say, officers are treated in wards 
just as enlisted men, there being a ward on the second floor reserved 
for. them. The number of rooms is very small. These are well fur- 
nished and contain every convenience, but have to be kept for seri- 
ous cases only. 

There is no separate building for contagious diseases, and at a date 
not very remote, many cases of smallpox were treated in the wards. 
The venereal ward is at the extreme end of the building, and this 
connects through a small room with an annex generally used for 
other contagious disorders. This annex is continued so as to form 
a court around the chapel, and contains smoking-room, baths, mor- 
tuary and post-mortem room. The kitchen is to the left of the 



NOTES ON NAVAL HOSPITALS. 245 

second entrance, near the quarters of the junior officers on duty, and 
to the right of this entrance is the administration. The grounds 
contain a botanical garden, and a promenade bordered by trees. 
Between these is the building for the medical school. 

The sisters, who have special quarters assigned them near the 
entrance court, nurse special cases and have the supervision of the 
male nurses. They also superintend the kitchen, laundry, store- 
rooms, and the like. There is one nurse for every twelve patients. 
The number of patients treated here is several thousand a year, and 
the mortality frequently exceeds four per cent. The hospital is in 
charge of a m6decin-en-chef. 

Naval Hospital of St, Mandrier, 

The coast in the immediate neighborhood of Toulon forms, as it 
encloses the two roadsteads, a curve somewhat like a parabola, with 
the axis nearly east and west. Toulon is on the north side of the 
curve, and the hospital Saint Mandrier on the south, distant from the 
city more than two miles, and overlooking the Grand Roads. Here 
the ground is high, and the extreme point is commanded by a fort, 
to guard the entrance to the roads. This fort is 900 yards distant 
from the hospital, which is sheltered by the intervening hills and the 
blufl' formed by the excavation necessary for a site. 

Unfortunately, jn the desire to protect the hospital from shells in 
time of war, so much excavating was done that the wind from the 
south is entirely excluded from it. In doing this a tremendous 
amount of labor was required, so that, though the work was com- 
menced in 18 1 7, under the design of M. Raucourt, an hydraulic 
engineer, it was not completed until 1830. Much of this work was 
done by convicts. The building erected at that time for their occu- 
pation still stands (800 feet long), and is used now for venereal 
cases, the laundry, and quarters for workmen. 

The grounds are 675 yards long and 255 wide, and exhibit by the 
amplitude the great amount of excavation required. The shore here 
can be approached by small boats, for which there is constructed a 
small dock ; but the main landing extends out 400 yards (Plate VII). 

The main buildings consist of three detached pavilions, one front- 
ing the bluff to the south, and the other two placed laterally nearer 
the water, and perpendicular to the first. They are each three hun- 
dred and sixty feet long and twenty-seven wide, but the breadth is 
doubled by strong covered balconies on the faces next the court. 



246 GATEVVOOD. 

These immense buildings, with their three stories, and adjoining 
grounds containing a botanical garden, beautiful walks and trees, and 
many detached buildings, including a classical chapel with its dome 
supported by many Ionic and Corinthian columns, present a glorious 
memorial of the greatness, gratitude and justice of France. And 
yet, the never-ending questions : should there be any grand hospitals 
anywhere ? — should not all hospitals be cheaply built, and frequently 
destroyed? — present themselves even here. 

There are 1200 beds within these walls and the many detached 
smaller structures. Most of them, however, are placed in the wards 
of the lateral buildings. These wards are 120 feet long, 27 wide and 
14 high, and contain 36 beds each, with more than 1200 cubic feet 
per bed. The floors are tiled, the walls plastered, and the ceilings 
wofully cut up by arches. There are windows on both opposite 
sides, but no other means of ventilation. The necessary heat is sup- 
plied by three open stoves, symmetrically placed in each ward. The 
climate, however, is remarkably mild, as is demonstrated by the 
tropical growth in the gardens. 

The front building contains, on the first floor, offices for the admin- 
istration, and quarters for the chaplains, chief medical officers, and 
sisters. These last superintend the kitchen, storerooms, laundry, 
and the nurses. On the second floor of this building are quarters 
for the junior officers, and small wards for the treatment of sick offi- 
cers. In the basement or ground floor are the laundry, kitchen, 
linen room, and the like, and also the pharmacy. 

Strangely enough, there is not a water-closet in the whole building. 
The system employed is that of perambulating closed stools, which 
are kept, for the most part, in the balconies, and emptied into an 
earth-pit. This, of course, entails many inconveniences, and makes 
cleanliness exceedingly difficult. 

Associated with this hospital are many detached buildings. In 
the rear of each lateral building is a series of parallel, temporary, 
detached wards, accommodating many patients. In front of the 
administration building are three enormous cisterns, remarkable for 
the capacity of 10 million litres. In regarding these caverns, one is 
impressed by the great work of those galley-slaves. 

Among the objections to this great hospital are the nearness of the 
bluff", and the obstruction presented by those very wide balconies to 
the admission of sunlight to the wards. But this large receiving hos- 
pital has been of immense value to France in her many wars ; notably, 



NOTES ON NAVAL HOSPITALS. 247 

in the Greek, Algerian, Crimean, Italian, and German campaigns ; 
and to Toulon in her many epidemics. 

In 1850, the botanical garden was transferred here from the hos- 
pital at Toulon. Every year, its connection becomes closer with the 
naval medical school in the south of France, and much work is done 
here now by the students, especially in surgery and clinical medicine. 

Naval Hospital at Cherbourg, 

Cherbourg was not designated as a naval station until 1781, from 
which time until 1793, the sick of the navy were treated in a civil 
hospital. When the large number of workmen in that locality made 
it impossible for this hospital to receive all the sick, an ancient abbey 
was placed at the disposition of the navy, which, after many changes, 
was converted into a naval hospital. Soon this became insufficient, 
and a new pavilion was added, containing three wards, holding forty 
beds each. The capacity was thus increased to three hundred beds. 
The grounds of this hospital contained a chapel, and many small 
buildings for mortuary, laundry, and quarters for workmen; and 
also a botanical garden. 

As Cherbourg increased in naval importance, additional quarters 
for the sick were obtained in a barrack. There were disadvantages 
in having the sick in two establishments so far apart, and, besides, 
the total number of beds was not sufficient for emergencies. Thus, 
after much consideration, large grounds were purchased west of the 
city, for the erection of a large modern hospital to contain 1000 beds. 
This hospital was not completed sufficiently for occupation until 
1870, and a portion of the plan still remains to be carried out. 
(Plate VIII.) 

It consists now of three detached pavilions, arranged like those at 
Saint Mandrier, except that the front one extends beyond the others, 
sufficiently for two additional outside rear-pavilions to be built in 
accordance with the original plan. 

The front looks to the north over the dockyard and Grand Roads, 
so that the rear pavilions haye the great advantage of being north 
and south, thus receiving much of the sun. A41 the buildings are 
three stories high, and contain about six hundred beds, though, 
usually, there are only two hundred and fifty patients. In front is 
a large garden and promenade. The enclosed court is also laid out 
as a garden, and is surrounded by a covered way which connects all 
the buildings, and which can be closed in bad or cold weather. 



248 GATEWOOD. 

The main structure in front is used for the same purposes as the 
corresponding building in Saint Mandrier, while the long, narrow 
wards are chiefly in the rear pavilions. The wards have polished oak 
floors laid in cement* and are warmed by stoves with porcelain sides. 
Besides numerous windows on both opposite sides, there are venti- 
lators near floors and ceilings. Each ward contains forty-eight beds, 
which are supplied with two mattresses and good springs. There 
are water-closets, urinals, and sinks near every ward, but well separ- 
ated from them. A male nurse looks after twelve patients, but as 
in all French naval hospitals, the sisters nurse special cases and have 
the general superintendence. 

The rear pavilions, which are over four hundred feet long, are 
distant from each other more than 200 feet. Occupying a part of 
the space between their rear ends is a large chapel, while in the 
corresponding space at the other end are the baths. These are most 
complete, containing in addition to the usual tubs, a swimming pool, 
a large variety of douches, and shower, sulphur, vapor, and hot-air 
baths. 

The laundry is in a separate building in the west rear corner of the 
grounds. It is complete in every respect, and has been recently 
erected at the cost of 300,000 francs. The mortuary is in the corres- 
ponding corner on the other side. There is a small wooden structure, 
rather too close to the main buildings, for the treatment of contagious 
diseases. 

The Naval Medical Schools of France, 

A description of the naval hospitals of France, however short, can 
scarcely be separated from some account of the Naval Medical 
Schools so closely connected with them. The French naval hospital 
dates back to the beginning of the regular organized navy in 1666, 
but the school did not follow until more than a half a century had 
elapsed. There were several conditions which finally necessitated 
their establishment. Soon after the foundation of Rochefort it became 
necessary to have capable medical ofiicers at the various naval stations 
where so many officers and workmen were being employed. 

Considerable care was exercised in their selection, with the result 
of obtaining good men. The inducements were sufficient to retain 
them in these positions for many years, as is shown in the case of 
Ollivier, who was, *' i'^ m^decin du port de Brest" for more than 
forty years. These in turn were succeeded by others, all remaining 
for many years, and attaching importance and dignity to the titles 



NOTES ON NAVAL HOSPITALS. 249 

" M6decin du port" and " Chirurgien-major du port." Some of these 
gentlemen represented the best talent in the whole kingdom, and 
were doctors of medicine of the best faculties in France. 

On the other hand, the medical service afloat was made of different 
material. For some time, commanding officers of ships selected their . 
own surgeons from such material as presented, and they held their 
places for short times only, and under other great disadvantages. 
Then a few surgeons were appointed at each port who were availa- 
ble for sea service, but their assistants continued to be appointed in 
the same manner. At this time there existed in the navy, as on 
shftre, both the physician and the surgeon. The latter was, as a rule, 
illiterate, and had obtained his small knowledge as an apprentice in 
the office of some surgeon in the large cities. 

The former, though the better educated, was generally one of little 
worth, who, in spite of the disadvantages of life at sea, resorted to 
the navy as a means of livelihood. In their education they had also 
imbibed a contempt for the surgeon as a class. Out of this condition 
of things only dissatisfaction could come. 

The various medical officers of the ports soon became aware of the 
great need of improvement. A short time after M. Dupuy was 
appointed " i" m^decin" of the port of Rochefort (1712), the estab- 
lishment of a naval medical school became the great object of his 
life. This gentleman, who was a graduate of the faculty of Toulouse 
and a member of the Academy of Sciences, repeatedly urged upon 
the government the necessity for such institutions. 

Disheartened by no failure, he finally accomplished his object, and 
succeeded, in 1722, in having a suitable building erected for the pur- 
pose, at which time this school was opened at Rochefort, with much 
formality. The success of the project was soon assured, and its influ- 
ence became so apparent that two other schools were soon established, 
the one at Toulon, in 1725, and the other at Brest, in 1731. 

These schools have commanded the admiration of the world ever 
since ; and in spite of the many successions of kings and of the Reign 
of Terror itself, they have always been fostered and prized by the 
French people. 

M. Dupuy is marked in naval history by his thorough grasp of 
a subject so important to the future welfare of his country. In 
England the purpose of the Naval Medical School is to complete the 
education of their assistant-surgeons acquired at the various medical 
schools of the country, but in France the object is to de/^tn that edu- 



2SO GATEWOOD. 

cation, and carry it on to a high grade of perfection. These schools 
have been so ably described by Medical Director Richard C. Dean, 
of the United States Navy, that all the remaining remarks upon this 
subject may be considered as a r6sum6 of his remarkably complete 
report. 

The student is taken as a youth over eighteen years of age, and 
impressed, from the beginning, with naval methods. He must be a 
citizen of France, without physical fault, and have arrived at the 
dignity of an A. B. or a B. S. Dismissal from one school for defi- 
ciency in studies, or infractions of discipline, bars him from the other 
schools and from naval life. There are two divisions in the school, 
and promotion from one to the other is determined by examination 
at the end of one year. This is a good arrangement, as two failures 
(one year interval) to pass from the lower to the higher division, 
leads to dismissal and rids the school of the trouble of working and 
spending money u(>on unsatisfactory material. 

The professors are permanently attached to the school. They are 
assisted by " fellows " who have arrived at that dignity after a special 
examination. These latter are liable in time to sea service. Every 
subject is lectured on three times a week, and each course is com- 
pleted once in two years. Thus, after two years study, the successful 
candidate becomes an assistant-surgeon ; and, after two years more 
study, if successful, a surgeon of the second class. 

An assistant-surgeon is not considered prepared for service at sea, 
as he has been examined only on the following subjects : 

1. Anatomy, performance of dissection (oral). 

2. Pharmacology, extemporaneous pharmacy (oral). 

3. Minor surgery, application of apparatus and bandages (oral). 

4. General pathology and semiology (written). 

After this examination he remains under instruction for another 
two years, with the exception of six months at sea, and is then exam- 
ined for promotion to the grade of surgeon of the second class. This 
examination is on the following subjects : 

1. Anatomy and physiology (oral). 

2. Materia medica and therapeutics (oral). 

3. External pathology, operative surgery, obstetrics (oral). 

4. Internal pathology, hygiene, legal medicine (written). 
Having passed this examination, he is granted six months leave 

for the purpose of procuring the degree of " doctor of medicine " 
from one of the faculties of France. The government defrays all the 
expenses entailed by this leave in the event of success, and in return 



NOTES ON NAVAL HOSPITALS. 2$ I 

demands a written contract to remain in the naval service for ten 
years. 

The examination for promotion to the grade of surgeon of the 
first class is also held at the school, and embraces the following 
subjects : 

1. Physiology (oral). 

2. Clinical medicine (oral). 

3. Operative surgery, obstetrics, performance of one surgical and 
one obstetrical operation (oral). 

4. Naval hygiene, pathology, a report on medical jurisprudence 
(written). 

The whole curriculum of studies is as follows : 

1. Legal and administrative medicine. 

2. Clinical medicine, medical pathology. 

3. Materia medica and therapeutics, toxicology. 

4. General and naval hygiene. 

5. Clinical surgery, surgical pathology. 

6. Operative surgery. 

7. Anatomy and physiology. 

8. Obstetrics, diseases of women and children. 

9. Chemistry. 

10. Pharmacy and medical physics. 

11. Natural history (medical), pharmacology. 

12. Descriptive anatomy. 

13. General pathology and semiology. 

14. Minor surgery, apparatus and bandaging. 

15. Extemporaneous pharmacy, chemical manipulations. 

To teach these various branches there are various amphitheaters, 
a library, a botanical garden, and a museum of natural history, 
pathology and anatomy. In addition to all this, the wards of the 
hospital form the great school, and in them clinical instruction is 
given in the most thorough manner. 

The final examinations for each grade are conducted at each school 
by professors from all of them. The examination is presided over 
by the director of the school at which the examination is held. He 
is assisted by one professor from that school, who has been deter- 
mined by lot. The other two come, one from each of the other 
schools, and have been selected in the same manner. All the ques- 
tions to be asked have been chosen by the medical council in Paris, 
from the number sent from all the schools. These questions, in a 
sealed envelope, with each question also sealed, and those for the 



252 GATEWOOD. 

different grades separated, are sent to the board of examiners after 
they have met in session. 

The candidate to be first examined is determined by lot, as well 
as the question to be first asked. All other candidates then with- 
draw, and are placed under guard in a distant room. As soon as the 
question is answered, the same question is put to each of the others, 
the order being deiermiiied by lot. Thus a separate question is 
drawn at each day's session. As a candidate answers, each professor 
places after the name his estimate of the value. When the answer 
is written, it is placed in a sealed envelope, and is read aloud next day 
by the candidate in public. Afterlhe last question has been answered, 
there is prepared, in secret session, a list of all the candidates, with 
tile marks of each professor opposite his name. This list is sent to 
Paris, where a superior commission is appointed, to consider these 
marks and make the final classification. The minimum for each 
grade is 200, and 20 is the maximum for each question. No one can 
serve as a member of the examining board who is, in any degree, a 
relation or a connection of any student. Analternate, selected by lot, 
is available for any such emergency. This remarkable method 
demands no criticism here, but suggests many. At any rate, it pre- 
cludes all prejudice, favoritism, and mercy. 

Before leaving this subject, something must be said about the dally 
routine. The work begins at eight o'clock, before breakfast, aod 
starts with an hour's clinic in the wards, followed by an hour's lecture. 
The lecture is generally from manuscript. Attendance is obligatory, 
and the subjects to be lectured upon, with the day for each, are posted 
on the bulletin board every week. After the lecture comes the hour 
for breakfast, followed by another lecture lasting an hour. After this, 
there are three hours passed in the dissecting-room or laboratory. 
This routine seems to demand a great deal from young men before 
breakiast. but is in accordance with the French method of living. 
There are generally over 100 students at each school, and of these, 
about 10 per cent come up to the requirements. 



Naval Hospitals of the United States. 
The history of the navy of the United Slates begins as early SB 
October 13th, 1775 ; hut there was no attempt to establish naval hos- 
pitals until February 26th, 181 1. However, much before that date, 
provision had been made for the treatment of the sick and disabled 
seamen of both the navy and merchant service. 



4 



NOTES ON NAVAL HOSPITALS. 253 

When the partially erected palace of Charles II at Greenwich, 
England, was, in 1694, converted into a naval hospital, the tax for its 
maintenance was levied, not only at home, but also in the American 
Colonies, where each seafarer was required to pay a portion of his 
earnings to support an institution so far distant. The collectors were 
educating the American people then, and continued to educate them 
for many years, in a system which they themselves were to adopt 
after a century, with its many dark days, had been added to the past. 
1776 came, and a new flag was unfurled, which was soon carried at 
mastheads rapidly increasing in number. 

By July 1 6th, 1798, the number of American seamen had become 
so great, that Congress passed an act for the relief of the many sick 
and disabled. By this act, twenty cents per month were deducted 
from the wage of each seaman in a merchant vessel of the United 
States, and directors were appointed to control the expenditure of 
this hospital fund at the various ports. This was the beginning of 
the Marine Hospital Service, under which the sick of the sea could 
find refuge in various civil hospitals designated by the directors. On 
March 2d, 1799, the act of the previous year was extended so as to 
embrace the naval service ; the Secretary of the Navy being author- 
ized to deduct twenty cents each month from the pay of every officer, 
seaman, and marine. The benefits and advantages were to be the 
same as those accorded to the crews of merchant vessels of the 
United States. 

However, as might have been predicated, it was soon apparent that 
the navy could not, without many disadvantages, depend upon civil 
hospitals for the treatment of its sick. The men, passed from the 
control of their own officers, lingered in hospitals for considerable 
periods, and in many instances finally disappeared. It soon became 
the opinion that the good of the naval service demanded that it 
should have its own hospitals. Accordingly on February 26th, 181 1, 
Congress passed a law establishing naval hospitals. 

By this law, the Secretaries of Navy, Treasury, and War were 
appointed, for the time being, " Commissioners of Navy Hospitals," 
and to them the hospital tax accruing from the navy was to be paid, 
together with all fines imposed upon officers, seamen, and marines. 

This fund was augmented by $50,000 appropriated out of the 
unexpended balance of the marine hospital fund ; this being consid- 
ered the amount belonging to the navy from payments made prior 
to the passage of the act. These commissioners were authorized to 
procure sites for hospitals, and, where suitable buildings could not 



254 GATEWOOD. 

be purchased with the sites, to cause such to be erected. They were 
also required **to provide, at one of the establishments, a permanent 
asylum for disabled and decrepit navy officers, seamen, and 
marines." 

The act goes on further to say, that when any officer, seaman, or 
marine shall be admitted into any hospital, that that institution shall 
be allowed one ration per day during his continuance therein, to be 
deducted from his account, and that when any one is admitted who 
was previously entitled to a pension, this, during his continuance 
therein, shall be paid to the commissioners, and deducted from the 
account of the pensioner. 

Little, however, was done for ten years by these commissioners. 
The Secretary of the Navy, Mr. Hamilton, had hospital plans pre- 
pared by Mr. Latrobe, and was very anxious to execute, as soon as 
possible, the very desirable and very plain law. The other two 
commissioners were not in sympathy with the plans of the man 
knowing best the urgent needs of the service of which he was the 
head ; the opposition being based upon its permanency and stability. 
The importance of the subject increased by time; its advocates 
becoming more earnest each year. The good of the service demanded 
a better provision for the sick than was made by the inconsiderable 
establishments at some of the navy-yards. These were, in some cases, 
cast-off buildings and wretched hovels, destitute of every necessary 
comfort. The method of caring for the sick was constantly under- 
mining the discipline of the service, and diminishing the spirit of 
cheerfulness and content. 

It was more than ten years after the passage by Congress of the 
" act establishing navy hospitals," that the commissioners, changed 
by the various political currents, began to carry out the real intent 
of the law under which they were created. Then, land was purchased 
at Boston, New York, Philadelphia, and Norfolk, and appropriations 
were made for buildings. The difficulty with which the three com- 
missioners worked together, led, shortly after this (loth July, 1832), 
to Congress investing the Secretary of the Navy with all their powers. 
After this the work progressed more rapidly, and the navy was soon 
provided with hospitals in keeping with its promising future. As the 
history and description of each hospital are found below, it is only 
necessary here to give some idea of their internal organization and 
government. 

The book of •' Instructions for Medical Officers of the United States 
Navy " gives most of the required information. The medical officer 



NOTES ON NAVAL HOSPITALS. 255 

in charge of a naval hospital is responsible for the care and treatment 
of the sick, and for the discipline, cleanliness, and economy of the 
institution, which it is his duty to keep always in an efficient condi- 
tion ; and to this end he shall exact from his subordinates, employes, 
and patients, a proper obedience to his orders and to the laws and 
regulations of the navy. Medical officers, and all persons employed 
in the hospital, shall perform such duties as may be assigned to them 
by the officer in charge. 

No changes, except in cases of emergency, which shall be imme- 
diately reported to the bureau, shall be made in the hospital buildings, 
furniture and grounds — ^such as destroying or removing trees, or dis- 
turbing the soil around them ; and no bills for purchases or repairs 
shall be contracted without permission of the bureau. 

The medical officer in charge shall inspect all medicines, provisions, 
supplies, etc., that may be received, or shall cause them to be in- 
spected by a subordinate medical officer, who shall report to him 
their condition, etc. A record of the inspection shall be entered on 
the daily journal. He shall direct the medical officers in charge of 
the wards to present their case- papers to him once a week for exami- 
nation, and will assure himself that they are accurately and carefully 
kept. 

The officer in charge of the hospital shall detail a medical officer 
who, in addition to such professional duties as may be assigned him, 
shall perform the duty of *' officer of the day " for twenty-four hours, 
commencing at 10 A. M. The officer of the day shall make a tour of 
inspection through the wards, kitchens, mess and other rooms occu- 
pied by patients and employes, upon going on duty at 10 A. M., 
and during the afternoon at a different hour daily, and finally at 
night after the patients are in bed. A list of patients and employes 
who have received passes shall be furnished him, as early as practi- 
cable every morning, and all patients and others will be required to 
report their return to him. 

A journal shall be kept by him, which he shall sign at the end of 
his term of duty, at 10 A. M. ; in which he shall make a brief record 
of the following points, which are to be noted at the time of occur- 
rence: the condition of the wards, kitchens, mess, smoking and other 
rooms, at each inspection ; the condition of the meals served, as to 
quality and quantity ; the names and diseases of the patients admitted, 
and the places from which they are received ; the names, number of 
days subsisted, and disposition of patients discharged, and whether 



2S6 GATEWOOD. 

the necessary papers in each case are correct and complete; the 
names and conditions of patients and employes who have returned, 
or who have overstayed their leaves ; the confinement and discharge 
of offenders ; the reporting and detachment of officers, or their going 
upon and returning from leave ; the record of inspection of all articles 
received ; the object and finding of all boards of survey ; and finally 
such other matters occurring during his term of duty as it may be 
desirable to record. 

Medical officers in charge of wards shall be held resi>onsible for 
their order and neatness, and for the good condition of all within 
them. They shall exercise a personal supervision over the comfort 
and welfare of the sick, visiting them at least twice daily, and oftener 
in severe cases ; and they shall assure themselves that their direc- 
tions as to medicines, dressings, regimen, etc., are accurately and 
promptly carried out. They will, personally, take the temperature 
of patients, and will never allow this duty to be performed by the 
nurses. 

Patients should be accompanied, upon admission, with hospital 
tickets, but in cases of emergency they may be admitted without 
this paper, when the medical officer shall report the fact to the com- 
mandant of the station, with a statement of the emergency, and cause 
the necessary hospital ticket to be supplied. 

Convalescents may be detailed for light service, but shall not be 
retained in the hospital for that purpose after they are fit for duty. 

No patient in hospital shall be entitled to any service except that 
of the regular hospital attendants, nor shall any one except medical 
officers on duty, patients and employes of the hospital, be subsisted 
or lodged, without permission of the bureau. 

In hospitals the following diet table will be followed for patients 
when practicable, but the allowances to attendants' messes may be 
varied at the discretion of the medical officer in charge, provided the 
value of the ration be not exceeded : 

BREAKFAST. DINNKR. SUPPER. 

Sunday, 

Coffee (oz. i), pt. i. Roast beef, oz. 12. Tea (oz. J), pt. i. 

Bread, oz. 6. Bread, oz. 4. Bread, oz. 6. 

Butter, oz. i. Potatoes, oz. 10. Butter, oz. i. 

Stewed mutton, 0Z.4. Other veg's, oz. 4. Sugar, oz. i. 

Sugar, oz. i. Pickles, oz. i. Milk, oz. 2. 

Milk, oz. 2. 



NOTES ON NAVAL HOSPITALS. 



257 



Monday. 

Coffee (oz. i), pt. i. 

Bread, oz. 6. 

Butter, oz. i. 

Beef hash, oz. 4. 

Sugar, oz. i. 

Milk, oz. 2. 

Tuesday, 

Coffee (oz. i), pt. i. 
Bread, oz. 6. 

Butter, oz. i. 

Mutton hash, oz. 4. 
Sugar, oz. i. 

Milk, oz. 2. 

Wednesday. 

Coffee (oz. i), pt. i. 
Bread, oz. 6. 

Butter, oz. i. 

Beef hash, oz. 4. 

Sugar, oz. i. 

Milk, oz. 2. 

Thursday. 

Coffee (oz. i), pt. i. 

Bread, oz. 6. 

Butter, oz. i. 
Pork and beans 

(warmed), oz. 6. 

Sugar, oz. i. 

Milk, oz. 2. 

Friday. 

Coffee (oz. i), pt. i. 
Bread, oz. 6. 

Butter, oz. i. 

Fish chowder, oz. 4. 
Sugar, oz. i. 

Milk, oz. 2. 



Mutton, oz. 12. 

Bread, oz. 4. 

Potatoes, oz. 10. 

Other veg's. oz. 4. 

Pickles, oz. i. 



Tea (oz. i), 


pt I 


Bread, 


oz. 6 


Butter, 


oz. I 


Sugar, 


oz. I 


Milk, 


oz. 2 



Boiled beef, oz. 12. 

Bread, oz. 4. 

Potatoes, oz. 10. 

Other veg's, oz. 4. 

Pickles, oz. i. 



Tea (oz. 


1), 


pt. I. 


Bread, 




oz. 6. 


Butter, 




oz. I. 


Sugar, 




oz. I. 


Milk, 




oz. 2. 



Beef soup, 


pt. 


I. 


Tea (oz. i). 


pt. I. 


Pork, 


oz. 


12. 


Bread, 


oz. 6. 


Beans, 


oz. 


4. 


Butter, 


oz. I. 


Bread, 


oz. 


4- 


Sugar, 


oz. I. 


Potatoes, 


oz. 


10. 


Milk, 


oz. 2. 


Pickles, 


oz. 


I. 






Roast beef. 


oz. 


12. 


Tea (oz. i). 


pt I. 


Bread, 


oz. 


4- 


Bread, 


oz. 6. 


Potatoes, 


oz. 


10. 


Butter, 


oz. I. 


Other veg's, 


oz. 


4- 


Sugar, 


oz. I. 


Pickles, 


oz. 


I. 


Milk, 


oz. 2. 



Fish, oz. 12. 

Bread, oz. 4. 

Potatoes, oz. 10. 

Other veg's, oz. 4. 

Pickles, oz. i. 



Tea (oz. I), 


, pt I. 


Bread, 


oz. 6. 


Butter, 


oz. I. 


Sugar, 


oz. I. 


Milk, 


oz. 2. 



258 GATEWOOD. 

Saturday, 

Coffee (oz. i), pt i. Bean soup, pt i. Tea (oz. i), pt i. 

Bread, oz. 6. Stewed mut'n.oz. 12. Bread, oz. 6. 

Butter, oz. i. Bread, oz. 4. Butter, oz. i. 

Beef hash, oz. 4. Potatoes, oz. 10. Sugar, oz. i. 

Sugar, oz. i. Other veg's, oz. 4. Milk, oz. 2. 

Milk, oz. 2. Pickles, oz. i. 

A special diet list shall be kept for each ward, which shall be 
revised and corrected every morning by the medical officer in 
charge of the ward. 

Admission of Patients, 

The following forms are to be observed : 

{a) When the hospital ticket is found correct, endorse and file it, 
with accompanying papers relating to the case ; if defective, return 
to the medical officer signing, when he is at hand; or otherwise, 
through the bureau. 

(J>) Enter name, etc., as follows: (i) In the general alphabetical 
register of patients, which is the permanent hospital record, for future 
reference. (2) In the abstract of patients. 

(^) Open case-paper. 

(^) If seaman from the receiving ship or other vessel, send ration 
notice to commandant of receiving ship as paymaster's notification ; 
if a marine from the neighboring barracks, send the ration notice to 
the commanding marine officer through commandant. 

Discharge of Patients. 

No person shall be discharged from the service for physical disa- 
bility, without having been previously surveyed by a board of 
medical officers. A copy of the report of survey and of any other 
paper relating to the patient, shall be appended to the case-paper, 
which shall be signed at its conclusion, or on detachment of the 
officer, by the medical officer in charge of the patient's ward. Case- 
papers will be verified by the signature of the medical officer in charge 
of the hospital. When a patient is discharged from hospital, the fact 
shall be entered upon the register of patients, and also upon the 
case-paper, which is then to be filed with the hospital ticket attached. 
The ration notice shall be forwarded through the commandant of the 
station. On every Monday, a report of the sick for the preceding 



NOTES ON NAVAL HOSPITALS. 259 

week shall be made in triplicate, one copy of which shall be sent to 
the comrtiandant of the station, one to the bureau, and the other 
retained for the files of the hospital, as a basis for the report of the 
following week. 

Medical Department^ United States Navy. 

By an act of Congress, 31st August, 1842, reorganizing the Navy 
Department, the various bureaus were created, and the management 
of the medical department was vested in a single head, denominated 
Chief of Bureau of Medicine and Surgery. It was required that this 
officer should be chosen from the surgeons of the navy. On Sep- 
tember ist, 1842, William P. C. Barton, M. D., was appointed the 
first chief of that bureau. On March 3d, 1871, the title of Surgeon- 
General of the Navy was conferred, and with it the relative rank of 
Commodore. 

At the same time the relative ranks of the officers of the medical 
corps were designated as follows: Medical Directors, with relative 
rank of Captain; Medical Inspectors, with relative rank of Com- 
mander; Surgeons, with relative ranks of Lieutenant-Commander 
and Lieutenant ; Passed-Assistant Surgeons, with the relative ranks 
of Lieuten.mt and Lieutenant (Junior Grade) ; and Assistant Sur- 
geons, with the relative rank of Ensign. With the exception of the 
Medical Directors, these officers serve both afloat and ashore. 

Candidates for admission to the medical corps are examined at 
the Naval Hospital, Brooklyn, New York, by a specially selected 
board. Permission to appear before this board is obtained from the 
Secretary of the Navy. 

Attendants on the sick at the various hospitals are male nurses, 
selected from civil life by the medical officer in charge of the institu- 
tion. They are paid from $15 to $25 per month, and are subject to 
instant dismissal for incompetency or misbehavior. The number 
employed is about one to every eight patients. 

The naval hospitals of the United States are situated at Widow's 
Island, Maine; Portsmouth, New Hampshire; Boston, Massachu- 
setts ; Brooklyn, New York ; Philadelphia, Pennsylvania ; Washing- 
ton, District of Columbia; Annapolis, Maryland ; Norfolk, Virginia; 
Pensacola, Florida; Mare Island, California, and Yokohama, Japan. 
The total capacity of these is 823 beds, and the daily average number 
of patients is about 225. In the navy are 10,500 officers and enlisted 
men. 



260 GATEWOOD. 

Naval Hospital on Widow's Island^ Maine, 

On Widow's Island, Penobscot Bay, Maine, is a naval hospital, 
specially constructed for the quarantine and treatment of the sick 
with yellow fever. It is a novel hospital, in that the permanent 
building is chiefly for administration, while the wards are portable 
Ducker hospitals, packed away until necessity shall require their use. 

The history of this institution is rather peculiar. In 1885, the 
Isthmus of Panama was the scene of considerable naval activity, as 
the United States was under the necessity of having a force on shore 
and a squadron in that locality. The presence of so many ships in a 
part of the world so often the home of yellow fever, induced the idea 
that it would be wise to provide a suitable refuge for infected vessels. 
This situation was the exciting cause of the construction on Widow's 
Island, but a strong predisposing cause is found in the proximity of 
the old quarantine station near Portsmouth, New Hampshire, to 
sections frequented by summer visitors. 

The island had been purchased by the government for lighthouse 
purposes, but, as it was not required for that use, it was offered to the 
Navy Department to meet the supposed necessities of the time. It 
contains 15 acres, has a height of 100 feet above sea-level, is bounded 
by East Rockland Bay and Fox's Island Thoroughfare, and is 12 
miles from Rockland and 2 miles from North Haven. The place 
could scarcely be more segregated, but, in time of need, special 
transportation of supplies from Rockland could be easily provided for. 

At the time of its selection it was almost barren, being destitute of 
trees and shrubs, and even water. However, the deep water near at 
hand, where the largest ships could swing at anchor, and the situa- 
tion so far north in a summer climate opposed to the spread of the 
yellow scourge, made it a desirable place for the purpose. A well, 
furnishing potable water, was soon made by boring, and a temporary 
wooden building was constructed in 1885, under the design and 
direct guidance of Surgeon A. C. Heffenger of the navy. There was 
fortunately no occasion for its use, but as the idea still prevailed that 
some future time might develop a pressing need for such an estab- 
lishment, Congress appropriated $50,000 for a permanent structure. 

This was begun June 4th, 1887, and completed, together with the 
pump-house and mortuary, on the following February. A wharf 
was also constructed on the southwest side of the island, where the 
land slopes gently to the water. All the rest of the coast is precipi- 



NOTES ON NAVAL HOSPITALS. 26 1 

tous. By the approval of the Surgeon-General, Surgeon Heffenger 
furnished the design, and the work was also carried on under his 
supervision. 

The following description was written by him in 1888: 

*' The plan of the present hospital embraces a finished basement of 
eight feet, and two stories of twelve feet each. Its dimensions are 
ninety-six by fifty feet. The basement is built of granite, with granite 
water-table ; and the walls are built of brick, with a thickness of six- 
teen inches. It is placed on the highest point of the island, founded 
upon solid ledges, and facing the southeast. A wide verandah 
extends across the entire front and for some distance on either side of 
the hospital. The roof is of slate, and is surmounted by a cupola 
and flagstaff. 

In the basement are the laundry, ironing room, drying room, dis- 
infecting room, and numerous storerooms. On the first floor are the 
dispensary, reception-room, ofiicers' dining-room, patients* dining- 
room, attendants* dining-room, kitchen and pantry. On the second 
floor are three officers' wards, three wards for men, a linen room and 
two attendants' rooms. A dumb-waiter extends from the basement 
to the second floor. In the north corner in the basement, and upon 
both floors, is a room fitted with lavatory, water-closets and bath-tub; 
thus there is but one soil-pipe in the building, and that runs direct 
from the basement through the roof, where it is properly covered 
with a ventilating cowl. All the plumbing and plumbing fixtures are 
exposed, and have been thoroughly tested. 

Two water-tanks, with combined capacity of three thousand gallons, 
are placed in the attic, and water is pumped into them from the arte- 
sian well by a Rider caloric engine of six-inch cylinder, and deep 
well pump. To ensure a sufficient volume of water for using this 
pump, a reservoir six feet in diameter and twenty feet deep was 
blasted from the upper end of the well tube, the capacity of which 
more than equals that of the combined tanks. A two-inch distribu- 
ting pipe runs from the tanks down to the basement, and a fire-plug 
with hose attachment is provided on each floor and in the basement. 
The tell-tale and overflow lead into the laundry tubs. 

The drainage is excellent ; the main sewer pipe running down the 
southwest slope from the rear of the hospital into Fox Island Thor- 
oughfare, where it terminates below the level of ebb-tide. A manhole 
and trap are provided just outside the building, and again imme- 
diately above high-water mark." 



r^^ 



262 GATBWOOD. 

** The barren and altogether unprepossessing aspect of the island 
rendered it advisable to make such improvements upon the grounds 
as the limited amount of the appropriation would permit. A number 
of walks were laid out and graveled. About two hundred and fifty 
spruce, fir, and hardwood trees were planted on the borders of these 
walks, and upon other parts of the island, and a lot for a cemetery 
was ploughed up, leveled and planted in grass seed. The ground 
immediately around the hospital was graded, terraced, covered with 
sea gravel for some distance, and sown in grass seed outside the 
margin of gravel. 

The hospital furniture was received and put in place during June» 
1888. It is plain in design, of excellent quality, and ample for the 
probable requirements of the station. The iron bedsteads with woven 
wire mattresses manufactured in Hartford, Conn., merit special 
notice. The pneumatic tubes and bells which connect all parts of 
the hospital are also worthy of special mention. 

The provision of Ducker Portable Field Hospitals is of great value 
to this station, as it makes it possible, under any ordinary demands, 
to treat all contagious cases outside of the main hospital, which can 
thus be reserved for treatment of non-contagious cases, and adminis- 
trative purposes. 

A small dead-house, with a cast-iron revolving autopsy table and 
concrete floor, is placed some distance from the other buildings, 
and affords excellent facilities for post-mortem examinations. 

The station as now equipped, including main hospital building and 
Ducker pavilions, accommodates fifty patients, and this number 
could be doubled or quadrupled by simply adding more Ducker 
pavilions.*' 

[/, S, Naval Hospital at Portsmouth, New Hampshire. 

There are two islands close to the Maine coast-line and the city of 
Portsmouth. New Hampshire, that are used by the United States for 
naval purposes. They are called the Pudding ton Islands, and are 
connected by bridges with each other and the Maine mainland, to 
which State they once belonged. They were a part of the discovery 
of Martin Pring in 1603, charted by John Smith in 1614, and 
included in the grant to Sir Fernando Gorges in 1639. 

In 1800 the government purchased from William Dennett the one 
nearer the mainland, for $5500. The other to the south, known as 
Seavey's Island, did not become the property of the government 
until 1866, when the 26 owners parted with it for $105,000. 



NOTES ON NAVAL HOSPITALS. 263 

The navy-yard was established on the one first bought, soon after 
the purchase. There was, however, no local provision for the care of 
the sick until 1834, when a small vacant frame building, constructed in 
1802, was repaired and furnished for that purpose. It could accom- 
modate but ten patients with any comfort, though occasionally 15 
were treated there at one time. In 1865, certain alterations were 
made, increasing its capacity to 25. It was then, however, more than 
60 years old, and soon the necessity for a new building became 
apparent. This subject was agitated from year to year, until in 1888, 
the Surgeon-General reported the old hospital beyond repair, and in 
every respect unfitted for the treatment of the sick. 

Congress, on March 2, 1889, and on June 30 of the next year, 
appropriated $43,000 for the construction and furnishing of a new 
building. Work was commenced in September, 1890, and the build- 
ing, with its various outhouses, was finished in a year, and commis- 
sioned on December 21, i89i,when the old hospital was abandoned. 
The old frame structure still stands in its dilapidated condition — one 
of the few wooden relics of the early days on the island. 

The new site is on the west shore of Seavey's Island. This island 
was selected because it was important to have the hospital outside of 
the yard, and yet easily accessible. Next the Piscataqua river, and 
between it and the road connecting the bridges in the north with 
Fort Sullivan in the south, 3} acres were set apart for hospital pur- 
poses. 

The building, which is about 83 feet long and 54 wide, is con- 
structed of brick, and fronts the south, with its length north and 
south. It consists of a cellar, 3 stories and an attic, under a pyramidal 
roof, surmounted by a ventilating cupola. The front projects for two 
stories, forming a small tower, on each side of which are short 
enclosed piazzas. 

The hospital, though new, is built on the corridor plan, there 
being a single central hall 10 feet wide on each floor, connecting the 
back and front. On each side of this are placed the wards and rooms. 
Little more need be said about the arrangement, as a reference to the 
plan submitted will be sufficient. The three wards are on the second 
floor. Sick officers and the resident medical officer have quarters on 
the third floor. The first floor is given up to administration, the 
dining-room and kitchen. (Plate IX.) 

The pitch of the first floor is 10 feet ; of the second, 1 2 feet 3 inches, 
and of the third, 11 feet. There are beds for 26 patients, with 1060 



264 GATEWOOD. 

cubic feet of air space to each. In the officers' wards the air space b 
2970 cubic feet for each. 

The floors of all the wards are of Georgia pine, on an under-floor- 
ing. The windows have double sashes, this being necessitated by 
the severe winters. They are provided with hinged lights. There 
are also 3 brick air-shafts extending the whole height of the building 
and connecting with the ventilating stack, while registers are near 
ceilings and floors, and cold air ducts from the exterior lead to the 
bases of the radiators. The radiators, which are placed at conveni- 
ent points throughout the building, are supplied with steam from the 
boiler-house in the rear. Gas for lighting purposes is made on the 
premises. 

The water-closets are at the back of the building, as well separated 
from the wards as the ground plan permits. They are supplied with 
overhead tanks and all modern improvements. The bath-rooms 
near by are well furnished. The traps to all fixtures have ventilating 
ducts, which finally discharge above the roof. The sewer system is 
an independent one, and empties into the adjacent waters. 

The source of the water supply is the ponds formed by damming 
the overflow from the springs near the center of the island. The 
boiler and laundry house is about 30 feet in the rear. The laundry 
has a concrete floor and wood ceilings, and is supplied with the mod- 
ern machinery of the Troy Laundry Company. The dead-house is 
at the northwest boundary of the grounds, near the water. 

The stafl* consists of a surgeon and a passed-assistant surgeon. 
The former is also the surgeon of the navy-yard, where he is pro- 
vided with a residence. The total number of patients treated last 
year was 86. 

Seavey's Island contains 105 acres of uneven and hilly ground^ 
well suited for farming purposes. The surface soil is, however, gen- 
erally shallow and covers granite. The views from the island are 
extensive and attractive. The winters are long and severe, while the 
summers are short and mild. Storms are not uncommon, and fogs 
are not rare in summer. July and August are the warmest months, 
the thermometer perhaps reaching 85° F. February is the coldest 
month, as then the mercury may be 10° or 15° below zero F. The 
mean annual temperature is 44° F. The location is free from 
malarial influences, but rheumatism, neuralgia and bronchial disor- 
ders are common. However, the climate seems conducive to a long 
life, though typhoid fever is not uncommon in the city, and cases of 
phthisis last, as a rule, but a short time. 



NOTES ON NAVAL HOSPITALS. 26$ 

Naval Hospital at Chelsea, Massachusetts. 

As the policy of the government during recent years has been 
toward the concentration of the work of construction and repair of 
ships at two yards only, the navy-yard at Boston has, for the time 
being, diminished somewhat in importance, and, with it, the naval 
hospital, where the average daily number under treatment last year 
was only 17. 

This hospital is beautifully situated at Chelsea, a suburb northeast 
of the city of Boston, and separated from it by the Mystic river, 
spanned at this point by a substantial bridge, across which street 
cars closely connect the thickly populated suburb with the city 
proper. It is near the Boston end of this bridge that the navy-yard 
lies, less than a mile from the hospital. The hospital grounds are on 
the left bank, and occupy the angle formed just above the bridge by 
the Mystic and Mill rivers. 

On September 22, 1823, this tract, consisting then of 115 acres, 
was purchased for $18,000 from Dr. Aaron Dexter, of Boston, by the 
Secretary of the Navy, Secretary of the Treasury and Secretary 
of War, representing the government as *' Commissioners of Navy 
Hospitals." This tract has been reduced to nearly 75 acres by 
several encroachments, but this has been since the hospital was com- 
missioned on January 7, 1836. 

The hospital then was much smaller than it is now, as on July 14, 
1862, $71,500 were appropriated by Congress for its extension and 
repair. Adams and Jenkins were the contractors, who, completing 
the new portion by March 2, 1864, and thus furnishing room for the 
sitk, were able to remodel and repair the old portion by June i, 
1865. While this work was going on, Morris Tasker & Co., of Phil- 
adelphia, completed for $18,000 the arrangement for heating the new 
portion, and for the laundry and culinary work, placing the boiler 
and laundry in a detached building in the rear. 

Considerably prior to these changes, the surgeon's house was 
built. This is a large residence, 250 feet south of the hospital. It 
was erected at a cost of $11,500, this amount appearing in the 
{appropriation bill for the year ending 1857. 

The hospital is a large granite house, devoid of any special hos- 
pital plan, 148 feet long and 70 wide, with pyramidal roof, attic, 
three stories and cellar. It is on a slight elevation, and faces the 
river to the southwest, from which it is distant about 100 feet. The 



266 GATEWOOD. 

first floor is only slightly above the ground level, so that there are 
only one or two short steps at the main entrance under the project- 
ing portico. The portico is 27 feet long and 13 wide, extends to the 
level of the second floor, and has four columns of the Doric order 
placed in front. The first story is divided by a central hall, 23} feet 
wide, connecting the front and rear entrances. On the north side of 
this hall are the dining-room (21} by 66 feet), well lighted by seven 
large windows, the dispensary, the kitchen, and two storerooms. On 
the south side are dining-room for the junior medical officers on duty, 
the administration office, reception room, storeroom, and linen 
closet. 

From the rear of the main hall a stairway ascends to the second 
story. The pitch of all the stories is 14 feet, and the arrangement 
of the 2d and 3d stories is the same. There is a hall ward, 23 J by 
26} feet, supplied with one window and containing eight beds, all 
against dead walls. To the north are two wards of nearly the same 
size and arrangement as the preceding one, and a large ward running 
crosswise and corresponding with the dining-room below. This 
ward, 21} by 66 feet, with a window at each end and five on one side, 
contains 20 beds — ten against the dead wall and ten between the 
windows opposite. 

The nurse rooms, bath-rooms, and water-closets are between the 
long and smaller wards. The bowls in the water-closets are porce- 
lain, and well flushed from overhead tanks. The closets containing 
no windows are lighted by gas, and ventilated by an air-duct leading 
to the roof. Their very objectionable situation is inseparable perhaps 
from the general plan. 

To the south of the main hall, on the two upper floors, are larg^e 
well furnished rooms for sick officers and resident medical officers. 
The bath-room and water-closets are between the end rooms. Of 
course, all these various rooms and wards are arranged along inter- 
secting halls or corridors. The accompanying plate (No. X) shows 
the arrangement on the second floor, and more than suggests the 
obstruction to the free circulation of air throughout the building. 

It is useless to make any comment on the many beds against dead 
walls, and the many intersecting corridors. Every hospital should, 
of course, be considered with all the beds full, as this is the situation 
which best tests its plan. Here there are 100 beds with from 985 to 
1090 cubic feet air space and from 71 to 78 feet floor space to each ; 
but, as the number under treatment at one time rarely exceeds 30, 



NOTES ON NAVAL HOSPITALS. 267 

these figures mean ordinarily but little. The beds in the wards are 
iron, and supplied with a hair and a wire woven mattress. 

The floors are painted soft pine, and the walls are calcimined. 
However, in the third story hard pine floors have been laid, and 
the walls are painted plaster. 

In addition to the windows and doors, ventilation in some of the 
rooms and wards is assisted by shafts leading to the roof. There is, 
however, no complete system of ventilation. 

Electric call-bells are placed throughout the building, and electric 
lights are now being introduced — the work to be completed by July 
ist, 1893. Gas is supplied by the city, as is the case with water, which 
comes from the reservoir of the Mystic Water Company. The water 
is abundant and of excellent quality. The sewer system is complete 
and independent ; it discharges into the adjacent waters. 

The Walworth system is used in heating the hospital, the surgeon's 
house, and certain other rooms, such as the smoking-room in the 
wooden annex. The steam heat is, however, difiicult to control, 
and this in the variable climate leads to too great variations in 
temperature. 

The naval hospital grounds surround those of the marine hospital, 
which are off* to the east and comprise ten acres. These ten acres 
were inadvertently given by Congress to that service. When it was 
discovered that they, a part of the original purchase of 115 acres, had 
been paid for by money held in trust, $50,000 were added to the 
hospital fund in lieu of them. 

The original purchase was further reduced by several acres taken 
at the beginning of the Civil War for ordnance purposes. It is not 
clear how the Bureau of Ordnance acquired this ground, nor how 
many acres are claimed. 

The acreage left to the hospital is, however, most ample; it, indeed, 
represents quite a farm. Much of it contains many fruit, trees, while 
about the building and in other sections are ornamental trees, shrub- 
bery and flowers. 

Off" to the west, a quarter of a mile from the hospital, and in the 
low and moist ground near the point where the two rivers join, is the 
smallpox hospital, completed on 25th April, 1869, by Geo. W. Clark, 
of Chelsea, at a cost of $8000. To the north, and at the same 
distance, is the cemetery. This is separated from the hospital by a 
line of hills 100 feet high. These hills, on whose slope the hospital 
is really built, shelter the building from the strong northeaiit winds 
which often prevail. 



268 GATEWOOD. 

Nearer the hospital, about 40 feet from the north end, is the brick 
mortuary completed in 1865. There are also near-by many coal 
sheds, a new barn, stable, carpenter shop, conservatory, hotbeds, 
paint-shops, and other outbuildings. The grounds are enclosed by 
water and by brick walls. 

The staff consists of a medical inspector and two assistants. Dur- 
ing the last twenty years the total number of patients treated has 
been nearly 3000. 

Until recently this was the only naval hospital on the Atlantic 
coast of the United States entirely free from malarial influences. 
This renders it a desirable place for the treatment of the many 
malarial troubles originating during the southern cruise of the home 
squadron. 

£/. S. Naval Hospital^ Brooklyn^ New York. 

This establishment increases daily in importance as the navy 
gathers strength, and the navy-yard near-by becomes more and 
more the center of great activity in construction and repair. It is 
situated in the city of Brooklyn, in the State of New York, and, 
facing the west, overlooks the navy -yard, half a mile distant, and 
separated from it by a narrow intervening strip of the city. The 
grounds, now enclosed by high brick walls, comprised, originally, 
33 acres, but, on July 2, 1890, the United States Government sold 
to the city a little more than two acres. 

These 33 acres were the hill portion of the Schenck farm, purchased 
on May i, 1824, together with the mansion and farm buildings, for 
$7650. In this purchase the government was, of course, repre- 
sented by the " Commissioners of Navy Hospitals," while the parties 
of the first part were Sarah and Jane Schenck, widows, and Jacob and 
Ida Harris and Isaac and Mary Ann Harris. On April 19, 1833, the 
State of New York ceded to the United States its jurisdiction over 
this property. However, at the time of the purchase, the mansion and 
farm buildings were made ready for the reception of the sick of the 
navy, then treated in a house rented by the government, and were 
so employed until 1838, when the front or main portion of the present 
hospital was first commissioned. In 1840 the wings were added and 
the original plan completed. At the same time was constructed the 
building to the east of the north wing, which is now designated as 
the laboratory, but was originally used as a pest-house. 

The hospital is on an elevation 56 feet above high water, and the wall 
in front, separating the grounds from the city, is distant 200 feet, 



NOTES ON NAVAL HOSPITALS. 269 

while that to the south, where the main ^ate is, is 360 feet away. 
The building, fronting 197 feet, and consisting of full basement, two 
stories and attic, is constructed of marble from the Sing Sing quar- 
ries, originally white, but now a decided gray. The ground plan is 
like a modified H, the wings perpendicular to the front, and 49 feet 
wide, extending back y^ feet, but to the /roni only 11 feet. These 
forward extensions are really a part of the front or main building, 
the intervening space being occupied by an imposing portico 1 1 feet 
wide and lOO feet long, which, with its 8 square columns, supports a 
frieze and cornice suggesting remotely the Doric order. 

Though the columns extend from .the ground, the floor of the 
portico is on a level with the first floor. As the ground immediately 
in front of the building is higher than that in the rear, the basement 
is partly covered in front ; and the broad stone steps leading up to 
the portico spring from a terrace. This terrace is paved with stone 
flagging, and extends along the whole front, and for more than thirty 
feet on each side, where from each end steps ascend to a side entrance 
on the first floor. 

The paved court, which is open to the east, is lOO feet from wing 
to wing, and 60 feet deep ; this being also the depth of the main 
building, which has, at the back and thus toward the court, 8 square 
columns similar to those in front, but supporting piazzas 100 feet 
long and 10 wide for each floor. As the court is on a level with the 
ground floor, it is in the rear that the hospital presents its full height. 

A corridor nearly 10 feet wide extends the whole length of the 
mid-line of the front on every floor, and is joined by similar ones 
from the wings. On each side of these are the rooms and wards. 
Thus it is seen that this is a corridor hospital on the block plan. The 
different stories are reached by very broad staircases within the front 
where each wing joins. The staircase wells allow with the corridors 
a free communication of air throughout the building. 

All the sick, except commissioned officers, are on the second floor. 
Here are found 15 wards of varying sizes for the treatment of enlisted 
men, and rooms for laboratory employes and sick warrant-officers. 
The wards, which are divided into many classes in accordance with 
the character of the cases, are in the south wing and the front. The 
rooms are in the north wing, though there are rooms for nurses in 
both wings, and there is an operating room in the south wing. This 
latter is on the south side of the corridor. Its floor, 15X 11 feet, is of 
hard pine shellaced, and its height is 17 feet, this being the pitch of 



270 GATEWOOD. 

both stories. It contains one large window, and is bountifully sup- 
plied with instruments and all things necessary for successful work ; 
but, opening upon the corridor, its atmosphere is that common to 
the whole hospital (Plate XI). 

The largest wards are, of course, the four in the front extensions. 
These are 27 X21 feet, and two are supplied with four windows each, 
and the inner two with three each. These windows are necessarily 
on adjacent sides ; thus, as is the case throughout the building, leav- 
ing dead walls ; and like all the windows, though large, not extend- 
ing nearer the ceiling than 3 feet. All the other wards are about 
15X21 or 22 feet, and have two windows in each on the same side. 
The floors are, for the most part, painted soft pine, but recently a few 
hard pine floors have been put in. The walls are painted plaster. 

The beds are iron, and supplied with a hair and also a wire- 
woven mattress. Near each bed is a locker, a chair, and a small 
carpet-rug. The number of beds in a ward varies with the size of 
the ward, but as a rule, the allowance of floor space per bed is 65 
feet, and the cubic space 1 100 feet. As this hospital, with accommo- 
dations for 125 patients, has most of the time less than 50, the floor 
space and air space given each patient are ordinarily most ample. 
However, occasionally the number of patients reaches 100, and prob- 
ably hereafter this will occur more frequently. The rooms on the 
second floor of the north wing are chiefly for sick warrant-ofiicers. 
These are fairly well furnished, and have associated with them a 
dining-room and reception-room. 

On the first floor there are in the south wing, quarters for the three 
junior medical officers on duty ; in the north wing, a counting-room, 
quarters for the apothecary, and 5 rooms for sick commissioned 
officers, with reception and dining-room attached ; in the front are 
administration offices, board rooms, a mess-room for resident medical 
officers, 3 rooms for sick commissioned officers, a chapel and library, 
and a dispensary. The rooms for sick officers are well furnished, and 
have a homelike appearance. 

In the basement, which has a height of about 10 feet, and where 
the corridors are paved with stone flagging, are smoking and mess 
rooms for the men, kitchens, carpenter shop, storerooms, and quarters 
for laborers. The mess-rooms are two, one being for those on full 
diet. 

There are water-closets and bath-rooms on each floor, off" the cor- 
ridors at the ends of the wings ; those on different floors being imme- 



NOTES ON NAVAL HOSPITALS. 2/1 

diately above one another. The bath-brooms are 8Xi6 feet, while 
the rooms for water-closets ar^ about half the size. Some of the bath 
tubs are porcelain and others are copper. There are also appliances 
for various special and medicated baths. The water-closets are sup- 
plied with seats, porcelain bowls, flushed from overhead tanks, and 
urinals. The floors are concrete, and there is a large window in 
each room. The doors of these rooms open directly on the corri- 
dors, but the water supply for flushing is unlimited, and the sewer 
connections are well guarded by traps. 

There are in the building a dark room, and electrical appliances 
for surgical and medical treatment. Fireplaces are in almost all the 
wards and rooms, but the hospital is heated by steam and hot air 
supplied from the engine and boiler house in the rear. The same 
machinery that drives heated air into the building in winter, supplies 
cool air in summer. The means of ventilation are, besides doors, 
windows, and chimneys, air shafts in the walls, and roof ventilators 
over the staircase wells. 

The system of sewers is extensive and complete, not only for this 
building but for all others in the grounds. The manholes and vents 
are open, and the highest point of the system is connected by a ven- 
tilating duct with the chimney of the steam building. The pipes 
connect finally with the sewers of the city. 

The water supply is the same as that of the city, connection being 
made with the city mains. This allows many fire-plugs about the 
grounds. From the city is also obtained the gas which lights the 
whole building. However, the work of introducing electric lights 
has been begun and will soon be completed. 

Walking about the grounds, one notices the laundry close against 
the engine and boiler house, 50 feet in the rear of the hospital. This 
laundry is relatively new and is supplied with every necessary appa- 
ratus. There is also the long stone building like the wings, and 
built on the same line as the north wing, though 60 feet in the rear. 
It is 100 feet long and 50 wide, was constructed in 1840 at the same 
time the wings were built, and was known then as the pest-house. 
It is now called the Naval Laboratory, though it is simply a large 
reception and storehouse, with basement and two stories, from which 
medical supplies are distributed to the various ships and stations. It 
is in charge of a medical director, who has a commodious house in 
the north division of the grounds. This division is made by a high 
brick wall, extending approximately east and west, about 80 yards 



272 GATEWOOD. 

north of the hospital. Between the wall and the hospital are the 
mortuary, chapel, and a two-story building for contagious diseases. 
This latter building, called the smallpox hospital, is 200 feet from 
the main building to the northeast. Near it is a disinfecting 
chamber. 

The medical director in charge has a large residence in front of 
the north end of the main building. It faces the south, is forty-five 
feet square, with a large back building and has two stories. 

1 20 yards in rear of the hospital is the cemetery, whose register 
now numbers over 125a 

The staff of the hospital consists of a medical director, a surgeon 
and two assistant-surgeons. The number of patients is, of course, 
liable to great variations. The mortality ratio has also been very 
variable, at times comparatively small, and at others relatively large. 

U, S. Naval Hospital at Philadelphia^ Pennsylvania^ and Naval 

Home of the United States, 

Immediately after the passage of the law of 181 1, entitled "An Act 
establishing Navy Hospitals," itbecamenecessary for the navy to take 
charge of its sick on shore. It was, however, very poorly equipped 
for such work, as there was not under its control a suitable building 
anywhere for such an undertaking. Necessity demanded something 
in the way of sick quarters at all the navy-yards. At the old navy- 
yard on the Delaware, in the city of Philadelphia, a very small 
building was appropriated to this use. It was represented in 1813 as 
a wretched hovel, destitute of every necessary comfort for sick per- 
sons, and calculated to hold eight patients. At that time it was 
holding twenty-four, and the thought of each was simply to gather 
strength enough to desert. This state of affairs demanded immediate 
correction, and a frame building was accordingly erected by order of 
the department issued the same year. This was regarded at the time 
as only a temporary structure, but it was not until the 26th of May, 
1826, that the commissioners created by the act of 181 1 made a move 
to carry out in this locality the real intent of that law. Then the 
purchase was made of the "Abbot lot," the site of both the Naval 
Hospital and the Naval Home of to-day. 

This lot of 23 acres is situated on the left bank of the Schuylkill 
river, in the western section of the city of Philadelphia. It cost the 
government $17,000, and, as a part of the Pemberton estate of 150 
acres, has a long and interesting history. It is sufficient here to 



NOTES ON NAVAL HOSPITALS. 273 

State that the Pembertons bought their " plantation ** from the Penns 
in 1735, built a large square brick house and several brick outhouses 
on it, beautified it, and lived outside the city in good old colonial 
style. The British officers, attracted by the beauty of the place and 
its natural advantages, occupied it frequently during the war of the 
Revolution. Surgeon Thomas Harris, of the United States Navy, 
many years afterwards, influenced by the same qualities, impressed 
upon the *' Commissioners of Navy Hospitals " the desirability of 
acquiring possession of the lot of 23 acres, then the property of the 
Abbot family and containing the buildings. 

By the act of 181 1 the commissioners were required to provide 
at one of the hospitals a permanent asylum for disabled and 
decrepit navy officers, seamen and marines. It was decided to carry 
out here in Philadelphia this provision of the act. Accordingly, 
immediately after the purchase in 1826, the buildings were made 
ready to receive the sick and also a few beneficiaries, and the hospital ' 
at the navy-yard was abandoned. Then, under Mr. StricklsTnd as 
architect, and Surgeon Harris as superintesident, the work of con- 
structing the asylum was begun. It was called ** Asylum," as it had been 
so designated in the act establishing it, but soon there were many who 
regarded the selection of that term as unfortunate. The difficulty of 
making asylum and home synonymous was insuperable, but. it was 
not until July i, 1889, that the official designation became " Naval 
Home." 

In 1832 the building was under roof, but the Hospital Fund was 
so nearly exhausted that Congress, in July of that year, had to come 
to its relief by appropriating $33,900. So the work progressed, and 
toward the close of 1833 certain parts of the building were occupied. 
The old buildings were then deserted and the sick and the benefi- 
ciaries were transferred to the new home. A short time after this the 
other buildings were demolished and the bricks utilized to improve 
the walks. Work continued on the asylum, and it may be said that 
the building was not really finished until 1848. Over $195,000 were 
expended in construction, and Congress appropriated $93,000 of this 
sum, the remainder having been supplied out of the Hospital Fund. 
It remains now to give a short description of the building and grounds 
before passing on to the Naval Hospital, which is of much more 
recent construction. 

The grounds, in a great part surrounded by high brick walls, 
approximate the trapezoidal shape. The longer (1226 feet) of the 



274 GATEWOOD. 

nearly parallel sides is formed by the Gray's Ferry road, and the 
shorter (583 feet), to the west and near the river, by Southerland 
avenue. The side (947 feet) nearly perpendicular to these is at the 
south, and the long (1364 feet) side at the north. The home fronts 
the southeast and the long parallel, from which it is 223 feet distant 
It is a building 380 feet long, composed of a central structure, with a 
pavilion on each side, entering into the formation of the front and 
ending in a transverse building. A basement, two stories and an 
attic, broad verandas on the two floors of the wings, broad stone steps 
with a marble colonnade for the central structure, fine marble stair- 
ways in the interior, and vaulted masonry ceilings, and a domed 
chapel, give a general idea of the building. 

The beneficiaries number over 100, and each has a small room, 
three good meals a day, and a pound and a half of tobacco and a 
dollar each month. All the laundry work is done without any 
expense to him, and every reasonable convenience is supplied. 
Twenty years service, or serious disability in the line of duty, allows 
admission. On enteringf, all pensions must be allotted to the hospital 
fund. Before the building of the present hospital, the home was, of 
course, as much a hospital as an asylum. For hospital purposes the 
second floor of the south pavilion, the rooms in the transverse build- 
ing aod the attic were employed. 

It was in this Home that the germ of the Naval Academy originated, 
as it was under its first '* Governor,*' Commodore Biddle, that a class 
of midshipmen was formed, and professors were employed to teach 
them. The students were those preparing for examination, and the 
class was renewed year after year, until the founding of the Naval 
Academy in 1845. 

The Naval Hospital is in the same enclosure, 350 feet in the rear of 
the Naval Home, and 225 feet from the shorter parallel side of the 
grounds near the river. It is, with the exception of the stone base- 
ment, a brick building. It is 320 feet long, faces the southeast, and 
consists of a basement, two stories, and attic with mansard roof. It 
was designed by John McArthur, an architect, in 1865, when the 
appropriation for its erection was made. The work was begun in 
1866, with Dobbins Bros., Philadelphia, as contractors. After an 
expenditure of $172,500, the hospital was commissioned in July, 
1868. 

It consists of a central structure and two wings, all entering their 
full length into the formation of the front. The wings are pavilions, 



NOTES ON NAVAL HOSPITALS. 2/5 

over lOO feet long, ending in transverse buildings, and containing the 
wards, — the central structure being the administration portion. The 
wings, denominated northeast and southwest respectively, were 
originally aHke, but in 1886 the former was divided into rooms for 
beneficiaries from the "Home"; but these rooms have never been 
occupied by them. Indeed, no one lives in that part of the building 
but the chaplain of the Home, who has his quarters in the second 
story. 

The southwest wing remains as it was originally designed — on each 
floor is a long ward, 81 by 24 feet, and in the transverse portion a 
smaller ward, 21 by 20 feet, with nurse -rooms, and in the rear and 
across a short corridor, water-closets. The floors are all soft pine 
painted, and the walls are painted plaster. The full height of the 
ceilings is 15 feet. There are 14 windows in the large ward, placed 
symmetrically on the opposite sides, while in the small ward there 
are seven. Twenty beds are in one ward, and dve in the other. 
These are of the usual pattern, and are supplied each with a hair 
mattress on a wire-woven base. There are the usual lockers and 
chairs and electric call-bells. As the other wing is not us^d, the 
total number of beds is just fifty — twenty- five on each floor. The 
air space for each bed is 1400 cubic feet. The hospital was, of course, 
designed for fifty additional beds in the other wing. 

This total of 100 can be increased 50 by using the wards under 
the mansard roof This space is not used for the sick, as the ceiling 
of the long ward is low. However, in the transverse portion of the 
mansard are two rooms, 20 by 21 feet, with fairly high ceilings. 
These at present are used, one for a bag and hammock room, and 
the other for microscopic and photographic work. In the basement 
of the pavilion are a smoking-room corresponding to the long ward 
and two storerooms. 

The central structure occupies 118 feet of the front, and has a 
depth of 74 feet. This does not include its further extension of 52 
feet in an addition consisting of a basement and one story, contain- 
ing in the former the kitchen, and in the latter the dining-room and 
several pantries. In the basement of the main or central portion, 
there are, besides this kitchen, many storerooms, and quarters for 
employes. On the first and second floors are the administration 
offices, quarters for resident medical officers and for sick officers, 
reception-rooms, dining-room, dispensary, diet-rooms, bath-rooms 
and water-closets. Under the mansard roof are an autopsy room, 



2/6 GATEWOOD. 

and a ward 28 by 45 feet, now used as a lumber-room. In the rear 
of these, and separated by the corridors, are quarters for the servants. 
(Plate XII.) 

The entire building is lighted by gas and abundantly supplied 
with good water from the city. As the water pressure is insufficient, 
tanks have been placed under the roof, which are kept filled by a 
steam pump. Steam for heating purposes is supplied from the boiler 
house in the rear, where also is the laundry, well supplied with all 
necessary appliances. There, is good natural ventilation, and conse- 
quently it is seldom necessary to use the artificial means provided. 
These consist of openings near the floors, through which hot air 
comes, heated in its passage by the steam pipes contained in brick 
casings, and openings near the ceilings, through which the air is 
drawn into the chimney of the boiler-house by a fan. The sewer 
system is not altogether satisfactory, as it is too closely connected 
with that of the city, as there is a large sewer running through the 
hospital grounds which has an objectionable manhole not far from 
the building. 

To the north of the Home is the residence of the governor of that 
institution, and to the south is the residence for the senior medical 
officer of the Hospital. There is a garden south of the hospital, and 
various outbuildings, but no separate place for contagious diseases. 
The dead were once buried in the grounds, but the government now 
owns a place in one of the city cemeteries. 

The staff consists of a medical director and two junior officers. 
The beneficiaries from the Home furnish most of the patients. These 
are placed on the lower floor; the paralytics and other helple^ 
cases in the small ward. These old men, already near their end, 
furnish, of course, a large mortality, though they have the advantages 
of an almost model hospital. From July ist, 1868, to December 31, 
1892, there were 5346 persons treated in this institution. Of these, 
648 were discharged from the service or transferred to the Govern- 
ment Hospital for the Insane, and 392 died. As 303 of these were 
beneficiaries, the ratio of 73.32 deaths per thousand should excite no 
surprise. The largest number of patients under treatment at one 
time was 54 in 1872. The average number now is 25. 

U, S. Naval Hospital, Washington^ D, C. 

The first naval hospital at Washington was established in a build- 
ing near the navy-yard, rented for that purpose. The price paid 



NOTES ON NAVAL HOSPITALS. 2/7 

was $200 a year. This was succeeded by the one established at the 
navy-yard, and which was discontinued in 1843, when the sick were 
transferred to the Marine Headquarters. Afterwards, the Civil War 
caused these accommodation^ to be insufficient, and on June 8, 1861, 
a temporary naval hospital was established in the " Government 
Hospital for the Insane" near Washington; certain wards having 
been " appropriated by the Secretary of the Interior for naval pur- 
poses." These wards continued to be used until October i, 1866, 
and 1488 patients were treated, with a recorded death-rate of 31.6 per 
thousand. 

The increasing importance of the navy-yard, the number of naval 
vessels in the Potomac, the uncertainty attending the condition of 
war, and the disadvantages of having a naval hospital under the same 
roof with insane patients, induced Congress to appropriate $25,000, 
on March 14, 1864, for the construction of a new building. The cost 
of work and material being then very great, additional appropria- 
tions had to be made, until the total aggregated $115,000. The 
building was completed in July, 1866, and commissioned October 
ist of the same year. 

The grounds comprise three-fourths of an acre, and are situated 
near the navy-yard. About one-half was purchased June 4, 1821, and 
the remainder, March 30, 1865 ; the total cost being $7819.50. They 
form a trapezium, bounded by the streets of the city, and enclosed 
by a handsome iron railing, and present with the building, walks, 
grass and trees, an attractive appearance. 

The hospital is back from the street, fronts the south, and is 90 
feet long and 60 deep. A part of the depth is made by small exten- 
sions back and front, so that the ground plan resembles a cross 
with short arms. It is built of brick, and includes a basement, two 
stories, and an attic under a mansard roof. The pitch of the base- 
ment is 9 feet, and of the two stories 14 feet. The rooms and wards 
open on corridors. A central hall. 10 feet wide, connecting back and 
front, is crossed perpendicularly by a narrower one extending the 
length of the mid-line. The corridors thus form a cross, and divide 
each floor into four sections (Plate XIII). 

In the basement, the floor of which is somewhat below the ground 
level, are the apothecary's quarters, the kitchen, laundry, boiler 
room, coal-bunker, storerooms, bath-room and water-closets. On 
the first floor are offices, mess-room for the men, and quarters for 
all the medical officers on duty. On the second floor are dispensary. 



2/8 GATEWOOD. 

officers* ward, nurses* room, and four wards for enlisted men. The 
two rear wards are i8i X35 feet, and the other two, one at each end 
of the front, are 24X22 feet. They contain many windows, and have 
pine floors and painted plaster walls. The bath-rooms and water- 
closets on each floor are in the rear extension, which is 9 feet deep 
and 43 long. They contain good tubs, and well trapped bowls with 
overhead tanks. The sewer pipes connect with those of the city. 

In spite of the plan of this building, the ventilation is remarkably 
good. The large number of windows, the walled duct under the 
hospital communicating at each end with the outside air, and dis- 
charging into stacks containing the steam pipes, and the ventilators 
throughout the building near floors and ceilings, accomplish an excel- 
lent result. 

The water is from the city, but, as the pressure is insufficient, a 
steam' pump is provided in the basement, to force the supply into 
. two iron tanks placed in the attic. All the water is passed through 
a Loomis filter, to free it from the large amount of matter held in 
suspension. The building is heated by steam supplied from the 
boiler in the basement, and is lighted by gas from the city, but elec- 
tric lights are now being introduced. 

The present number of beds is 26, with an air space of 1392 cubic 
feet to each ; but the average number of patients daily under treat- 
ment allows over 3000 cubic feet to each. The hospital was designed 
for 50 beds, with 1155 cubic feet of air to each. In 1871 there were 
63 patients under treatment at one time. The staff" consists of a 
Medical Director and a Passed Assistant Surgeon, both of whom 
reside in the building. 

* 

*' Sick Quarters'' U.S. Naval Academy, Annapolis, Maryland, 

The United States Naval Academy, situated at Annapolis, Mary- 
land, on the right bank of the Severn river, is separated from the city 
by a high brick wall, which, with the river, encloses more than 60 
acres of ground. These are beautified with walks, lawns and orna- 
mental trees, and contain the many buildings necessary for the 
school. 

This school was established in 1845. on 9 acres of ground trans- 
ferred to the Navy Department from the War Department, which 
had here a small fort. Additions have been made by purchase from 
time to time, until the present ample dimensions have been attained. 

The hospital is near the south end of the main building, or "cadet 



NOTES ON NAVAL HOSPITALS. 2/9 

quarters/* and was built in 1853, to take the place of a small two- 
story frame structure near the fort. It is a brick building, 42 feet 
wide and 67 deep, fronts the east, and consists of a half-cellar, three 
stories and attic. Originally much smaller, it was enlarged and altered 
in 1876, and again in 1886. The cellar has a depth of 7 feet, is well 
ventilated, and its floor is of concrete. The storerooms situated here 
are therefore dry and ample. On each story there is a wide central 
hall connecting back and front, and having rooms or wards on either 
side. Broad iron stairways connect the different floors. 

The hall on the ist floor is tiled, and ends in a rear vestibule, from 
which the back stairway ascends. This stairway well is connected 
with the water-closets and bath-rooms on each floor, and is shut off 
from the rest of the building by doors. Contagious disorders can 
thus be treated on the 3d floor without any communication with the 
other parts of the hospital. 

It is true that a detached pavilion would be preferable, but the 
writer has known scarlet fever, mumps, diphtheria, and other com- 
municable diseases, to be repeatedly treated here without any exten- 
sion, thus apparently demonstrating the tendency of infectiQn to 
confine itself to the horizontal plane. 

The water-closets and bath-rooms are separated from the wards 
by doors and the staircase well. They have concrete floors and slate 
walls, two or more windows each, good tubs, and bowls well flushed 
from overhead tanks. All the fixtures are well trapped, and the 
sewer pipes connect with those from the " cadet quarters/' and 
empty into the river near by. The first story has a pitch of 8} feet, 
the second 12 feet, and the third 14 feet. On the first floor, on one 
side of the hall, is a large dispensary, communicating in the rear with 
a convenient laboratory, the dining-room, and nurses' room ; on the 
other side is the officer-of-the-day's room, communicating in the rear 
with a waiting room, the kitchen, and dentist's room. The kitchen 
is only used to keep the meals hot before serving. All the cooking is 
done in the kitchen of the '* cadet quarters." The laundry work is 
also done outside of the building in the main laundry. On the 
second story, the hall room is the operating room. This is lighted 
by three large windows occupying most of the walls, and contains 
the necessary appliances. On one side of the hall is the medical 
inspector's office and library, and two wards; on the other, two 
wards and the apothecary's room. 

The third floor has a dark room and six wards, one of which is 



'i^ 



imtptm 



280 GATEWOOD. 

called the board room, as the physical examinations of all the candi- 
dates for admission to the school and of all cadets are conducted 
there. The wards are all well supplied with windows extending 
nearly to the ceilings, and with ventilators near floors and ceilings, 
connecting with ventilating shafts. The attic is surmounted by a 
large ventilating cupola. 

Electric call-bells are distributed throughout the building. Large 
steam radiators are in suitable places, and connection is made with 
the boiler-house, from which most of the houses in the grounds are 
heated. Gas is obtained from the Naval Academy tanks, and water 
from the city reservoir, five miles distant. The source of this water 
is a small stream fed by springs. It contains 4 grains of solids to the 
gallon, of which 2.5 are non- volatile. 

The patients having accommodations in the hospital are chiefly 
cadets, of whom there are generally about 250 in the school. Officers 
connected with the academy have, as a rule, quarters within the 
grounds provided for them and their families. 

There are, however, many enlisted men in the marine barracks 
and on the ship>s located here. Serious cases among these are 
admitted into the hospital, and indeed from this source is almost all 
the mortality — there not having been a death among the cadets at 
the academy for several years. 

The medical officers on duty look out for the sick of over icoo 
people, including many women and children. The official returns 
include, of course, only such cases as occur among the persons in 
the naval service. During the last 3 years there were 3059 cases 
treated ; of these. 14 were invalided and 5 died ; the causes of death 
being phthisis, suicide and tetanus. In 1890, out of 240 cadets, 172 
were attacked with epidemic catarrh, but none of these cases ended 
fatally. 

The staff consists of a medical inspector, a surgeon and two passed 
assistant surgeons. The hospital can accommodate 50 patients and 
furnish 3500 cubic feet of air space to each bed. The number in 
sick quarters is, however, as a rule much below this, and each one 
probanly has not less than 5000 cubic feet of air. 

In the spring and summer the broad verandas on each floor furnish 
to convalescents opportunities that are not neglected of remaining 
out-of-doors in good weather. 

The mean annual temperature is 55° F., while that of summer is 
76°, and winter 35°. The rainfall is about 45 inches. The atmos- 



NOTES ON NAVAL HOSPITALS. 28 1 

phere in summer occasionally furnishes a high degree of humidity^ 
but the climate is remarkably good most of the year for a place situ- 
ated on the Atlantic coast. There is a mild malarial influence in 
summer and early autumn, but it is only occasionally noticeable, as 
the grounds are kept in beautiful order and are well drained* 
Indeed, it may be said that few places furnish such grass and trees 
and opportunities for outdoor life. 

U. S, Naval Hospital^ Norfolk^ Virginia, 

After 1811 the sick on this station were treated in a temporary 
hospital established at the navy-yard. It was a very poor structure^ 
and in a few years after its occupation was unfit for use, by reason 
of decay and other causes. It was not, however, until 1826 that the 
commissioners caused the various sites near Norfolk to be examined 
with a view to the erection of a permanent building. Craney Island 
was first selected, and its transfer from the War Department was 
secured in November of that year. 

This site was not very satisfactory, and the conditions attached to 
the transfer not altogether agreeable. Therefore on January 8, 1827, 
a request was made to the Secretary of War, himself a member of 
the Board of Commissioners, to transfer Fort Nelson, near Norfolk, 
and the public land attached to it, to the Navy Department for hospital 
purposes. The transfer was made, and 25 acres or more of adjoining 
land were purchased for $5000 from Col. Thomas Newton, then a 
member of Congress. The conveyance of the latter was not com- 
pleted until November 29, 1827. 

In December, 1826, a plan for the hospital had been accepted from 
John Haviland, an architect in Philadelphia, and the work was com- 
menced early in 1827, under his personal supervision. He also made 
all the contracts for material and labor and was responsible for the 
payments. On July 17, 1830, the sick, together with all furniture 
and appliances, were moved from the temporary hospital at the yard 
to the one wing of the new building sufficiently completed. This 
transfer was effected by Surgeon Thomas Williamson, U. S. Navy, 
the first medical officer in charge of the present naval hospital at 
Norfolk. In 1832, after an expenditure of $270,000, the building 
was still more or less incomplete, and indeed the work continued 
from time to time for several years. 

The hospital is well located on the left bank of the Elizabeth river^ 
opposite the city of Norfolk, and separated from the navy-yard by 



282 GATEWOOD. 

the city of Portsmouth. The grounds comprise 80 acres, of which 50 
in the rear of the building are covered by a pine forest, cleared of 
undergrowth and traversed by roads. The land in front is a broad 
stretch of lawn, ornamented by walks and trees, and surrounded by 
a sea wall terminating in a point projecting into the river 1000 feet 
away. 

This hospital, constructed of granite, presents an imposing appear- 
ance ; its basement and 3 stories being adorned by a portico 1 10 feet 
long and 1 7 feet wide, approached by broad stone steps, and containing 
10 lofty Doric columns supporting a handsome entablature and pedi- 
ment. The block plan was chosen, with a front of 195 feet facing the 
northeast, and two perpendicular wings extending 170 feet. The 
width of each is 44 feet, except for 123 feet of the wings adjacent to 
the front. Here the deficiency is supplied by an outside balcony on 
each floor. The fourih side of the square is occupied in part by a 
two-story annex, 60 feet long and 20 wide. This is joined to the 
wings by balconies that extend on every floor around the entire court. 

All the wards are in the wings ; each wing has eight on a floor, 
five being 26X 15 feet, and three 35 X 10 feet. They all connect by 
arched openings forming alcoves on each side, and except on the 
third floor have vaulted ceilings with a maximum height of iii feet. 
Each has two opposite windows, painted wood floors and plaster 
walls. Each contains 4 beds and furnishes 1087 cubic feet of air and- 
98 feet floor space to a bed. (Plate XIV.) 

A hall i2i feet wide traverses the length of the floors of the main 
building, having the rooms in front. Stairs from these halls connect 
the various floors. On the ist floor are offices, reception-room, and 
officers' dining-room. On the 2d floor are quarters for resident oflS- 
cers and for sick officers. On the 3d floor are storerooms, apothe- 
cary's room and quarters for employes. The nurses' rooms are in 
the wings, one at each end of the row of wards in the narrower por- 
tions, with water-closets opposite, and stairs connecting the different 
stories. These closets are used only by special cases, as the main 
water-closets are in the annex, where also are the smoking-rooms, 
wash-rooms, and barbershop. In the general basement are kitchen, 
laundry, mess-room, storerooms and quarters for employes. 

The court covers large cisterns, into which water is pumped from 
a deep well extending into a natural underground current supplying 
30,000 gallons daily. There are also large iron tanks on top of the 
annex for storing this water. The pump and boiler-house are in the 



NOTES ON NAVAL HOSPITALS. 283 

rear. Steam is supplied for heating the building, for the pumps in 
storing water, and in connection with a perfect fire system. Ventila- 
tion is accomplished by doors and windows; the long summers and 
mild winters allowing a free circulation of air most of the time. 

The sewer system is complete and independent. All fixtures are 
trapped and the abundant supply of water allows frequent flushing* 
The pipes discharge into the river north of the building. 

A number of electric lamps supply light; though, of course, the 
gas fixtures are retained, and connection with the gas-works of the 
city of Portsmouth. 

Well situated in the midst cflf pine trees is a frame building used 
for contagious diseases. There are also, of course, the usual out- 
houses, such as woodsheds, stables, greenhouse, and boathouse. 

To the south is a good residence for the medical director in charge. 
His assistants, a passed assistant surgeon and two assistant surgeons, 
reside in the main building. The south wing of the hospital is not 
used, as the average number daily under treatment is 30. This hos- 
pital was, however, designed for 200 beds. 

During the last 3 years 593 patients have been treated.' 

The climate is rather debilitating in summer, on account of the 
high temperature; though at night during this period there is gen- 
erally a pleasant breeze, allowing refreshing sleep. The spring and 
autumn are delightful, and the winters, as a rule, mild ; though snow 
and ice are common in January and February. 

In the early autumn, cases of malarial fever are not infrequently 
admitted from the navy-yard, and typhoid fever is not rare in the 
cities. Pulmonary troubles do better than in any of the other naval 
establishments, and patients are occasionally transferred here for ihat 
reason. 

The increasing importance of the Norfolk navy-yard, and ihe large 
number of naval vessels seeking these waters, make it very desirable 
to have a hospital so delightfully situated, and so entirely free from 
epidemic influences. 

U, S. Naval Hospital, Pensacola, Florida, 

This hospital is a light frame structure, situated three-quarters of 
a mile to the west of the navy-yard. The hospital and the navy- 
yard, with the little village of Wooster at its north, and the larger 
straggling village of Warrington at its west, are on the naval reser- 
vation, 5 miles by water southwest of the city of Pensacola. This 



284 GATEWOOD. 

reservation is part of the ungranted Spanish royal domain, which 
became the property of the United States by the treaty of 1819, rati- 
fied by Spain in 182 1. Florida ceded its jurisdiction over this tract 
to the United States in 1845. 'I*he coast here forms an angle that 
includes the reservation, the south and east sides of which are both 
on the Bay of Pensacola, while the Grand Bayou, formed by an arm 
of the bay extending west, forms the north boundary of the " reserve.'* 
The apex of the angle is called Tartar Point, and it is here that the 
navy-yard is situated. The soil is white sand, sparsely covered with 
grass. The trees are pine, and water and live oak. 

In seeking a site for the hospital, the higher ground at the west of 
the naval reserve was selected, and 15 acres were set apart by high 
brick walls. The building is 566 yards from the bay, and 42 feet 
above sea-level. It is a simple pavilion of five wards arranged in a 
row. Each ward has five beds, with 1047 cubic feet of air to a bed. 
This simple structure is 126 feet long and 30 wide, is surrounded by 
a balcony, and faces the south. The surgeon's house, near by, and 
to the west, has much the same appearance, and is but little smaller. 
In addition* to his quarters it contains two rooms for sick officers. 
These rooms have each 2260 cubic feet of air space. 

The two buildings, with their kitchen in common, were completed 
in October, 1875, by R. E. Anson, contractor, at a cost of $18,872^ 
and were immediately occupied. They occupy the site of the old 
hospital destroyed by fire during the Civil War. Reminders of the 
old structure can be found in the remains of such outhouses as the 
mortuary, bakery, laundry and engine-house. Since the building 
of the hospital, nothing has been done to improve the grounds by 
repairing or taking away these old relics. This is probably due to 
the relatively small importance of the institution. The sick of the 
fleet seek the northern hospitals, and the navy-yard is now one chiefly 
in name. Money, however, is expended in the way of preservation, 
and the hospital is kept clean and ready for emergencies. 

The ventilation is very good, as, in addition to windows and fire- 
places, there are doors provided with transoms, and in the ceiling of 
each ward are two movable blind ventilators. These latter open 
into the attic, which is ventilated by stationary blinds. The water 
supply is provided for by a cistern in which is collected the rain 
water from the shingle roof of the surgeon's quarters. The annual 
rainfall is 90 inches. 



NOTES ON NAVAL HOSPITALS. 285 

A portion of the grounds in front of the buildings is low, and here 
collect the drainage waters from the slope to the west around Fort 
Barrancas, and the opposed slope of the hospital grounds. The 
result is a sluggish pond, 210 feet long. The warm climate and the 
decaying vegetable growth so near Jthe hospital furnish, in the early 
&dl, conditions not favorable to the health of the locality. The 
winters are very mild, giving but little frost, and the summers are 
long and exceedingly hot. July and August are the warmest months, 
but September is probably the most debilitating. The mean annual 
temperature is nearly 70 degrees F., and the range in 1880, an 
exceptional year, was between 118 degrees and 7 degrees. 

The prevailing diseases are intestinal and malarial. Yellow fever 
is an occasional visitor — the years 1863, 1867, and' 1875 and 1883 
marking some of its visits. This disease is not indigenous, but 
sometimes passes from the quarantine station to the southeast on the 
long island of Santa Rosa. The hospital has no separate building 
for such cases, and in 1883, eight were treated in the wards. . 

The staff consists of one surgeon, who, in addition to hospital 
duties, does much work among the poor of the two villages. The 
navy has supplied only 271 cases since the hospital was commissioned 
in 1875. Of these, 12 died (6 from yellow fever), 209 were discharged 
to duty, and 50 were invalided. During a part of 1888 there was 
not an unoccupied bed, as 24 patients were under treatment at one 
time. But during the last four years there have been only 14 sick, 
as the naval force at the yard has been reduced to a minimum. 

U, S, Naval Hospital, Mare Island, California, 

The naval station of the United States on the Pacific is Mare 
Island, a tract of land acquired by the government on January 4, 
1853, at a cost of $83,000. It is situated 25 miles from the city of 
San Francisco, on San Pablo Bay, the northern extension of San 
Francisco Bay, and was originally a grant to Sefior Castro, who 
parted with it for money, as several others did before its final 
purchase. 

This island is very extensive if all the marsh land be considered, 
but only 930 acres are at all suitable for naval purposes. These 
include the rolling land, forming approximately an ellipse, com- 
prising the southern portion. The long axis of this is 2} miles, 
extending northwest and southeast, while the short axis is \ of a 
mile. 



286 GATEWOOO. 

Between the island and the town of Vallejo on the mainland is 
the Mare Island Strait. At the southern extremity (the Carquinez 
Strait) the waters of the Sacramento and San Joaquin rivers empty 
into the bay. .The formation of this part of the island is sandstone, 
covered by 2i feet of black loam. The climate and soil have been 
so favorable to the cultivation of trees and flowers that the island 
has become celebrated even on that coast. 

Soon after the purchase, the navy-yard was established on the side 
opposite Vallejo, the intervening waters furnishing a quiet anchorage 
for ships of any size. A building was set apart for *'sick quarters," 
and for storing medical supplies for the squadron and station. This 
is employed now as the dispensary and surgeon's office of the yard ; 
the large number of officers and workmen requiring medical and 
surgical assistance near at hand. It ceased to be used as *'sick 
quarters '* when the present hospital was completed in 1870. 

This hospital has an isolated position outside and to the south- 
east of the yard, being one mile from the workshops, and on a slope 
facing Mare Island Strait, and ending in an intervening marsh. It is 
66 feet above low water, and consists of a central structure, and two 
pavilions terminating in small transverse buildings. It fronts the 
east and is 250 feet long. It is built of brick, and has a basement, 
two stories, and an attic under a mansard roof. The spaces in front 
between the projecting central structure and the transverse portions 
of the pavilions are occupied by broad verandas on each floor. Elach 
floor of a pavilion is a ward ; the transverse projection containing 
bath-room and water-closet. 

Each ward is 68 feet long, 24 wide, and 15 high, and contains 
twenty beds between windows, and furnishes over 1200 feet air 
space and 81 feet floor space to each. There is an open flreplace 
near each end, 10 windows on both opposite sides, and an end window. 
The windows are gi feet high, and extend within 3 feet of the ceiling. 
The floors are painted Oregon pine, and the walls painted plaster. 
Fresh air is admitted by openings near the floor, connecting with 
ducts. A current is induced by ventilators near the ceiling commu- 
nicating with large Emerson ventilators opening above the roof and 
provided with steAm coils. The water-closets and bath-rooms are in 
the transverse projections on opposite sides of the wards. They are 
included in the ventilating system, have concrete floors, windows and 
all modern improvements. 

The basement has 5J feet of its pitch below the ground level. It 



NOTES ON NAVAL HOSPITALS. 28/ 

contains mess-room, reading-room, kitchen, storerooms, and quarters 
for employes. The floors of the central building contain offices, resi- 
dent medical officers' quarters, rooms for sick officers and for special 
cases, operating rooms, and apothecary's room. (Plate XV.) 

The whole building is heated by steam and lighted by electricity. 
The sewer system is independent. All fixtures are well trapped, and 
the pipes join the lo-inch sewer in the rear, which connects with a 
well ventilated brick sewer nearly 500 feet long, emptying at an 
inclination of one foot in forty into the adjacent waters. 

The steam laundry, drying-room and boiler are in a building 140 
feet south of the hospital. In an annex to this is the mortuary. The 
boiler supplies steam for heating the building, and for forcing water 
into the iron tanks under the hospital roof. Water is obtained from 
the water-works of Vallejo and from the reservoir on the island. 
The latter holds 13,000,000 gallons of rain-water, but this supply is 
regarded as a reserve: the large number of people living on the 
island making it unadvisable to trust entirely to the connection with 
Vallejo. 

The staff consists of a medical director, who is provided with a 
delightful residency, a surgeon and a passed assistant surgeon. Patients 
are received from the Pacific and Asiatic squadrons, from the station, 
and the Yokohama hospital. The 80 beds are, however, rarely 
filled, as the average number of patients daily under treatment is 
about 40. During the last three years 581 cases have been treated. 

The climate is regarded as salubrious. During six months of the 
year there is almost no rain. The rainy season begins in May and 
lasts until October, though during this period there are usually con- 
siderable periods of fine weather. The mean annual temperature is 
57° F. The thermometer occasionally falls to 28° in January, the 
coldest month. In summer there is a period of northwest winds, 
fogs and dust, that produces influenza and various respiratory 
troubles. Malarial influences are rarely noticeable, and epidemics 
unknown. 

C/. S, Naval Hospital at Yokohayna, Japan, 

This beautiful little establishment, constructed in 1872, and com- 
missioned on May 16 of that year, accommodates 34 patients, includ- 
ing 8 officers. It is delightfully situated amid the residences of 
the foreign population, and near the English and German naval 
hospitals, on the bluff southeast of the main or lower section of the 
city of Yokohama. 



288 GATEWOOD. 

It consists of a main quadrangular building of two stories and two 
detached buildings of one story. One of these, called the wing, is 
situated to the east and rear, so that its front is nearly on a line with 
the rear of the main building, with which it is connected by an out- 
side passage. The other building, containing the dining-room, 
kitchen, pantry, coolcs' room and store-rooms, is nearly 30 feet in 
rear of the main portion, and is connected with the wing by a pas- 
sageway. The whole hospital is constructed of tile and plaster, 
fronts the south, and is nearly surrounded by verandas on all stories. 

A smallpox hospital, with a disinfecting chamber near by, is no 
feet from the main building, and near the northwest limit of the 
grounds. It is a one-story building, containing a ward ^5X54 feet, 
and two rooms 14X 15 feet. The ward has 8 windows and a door, 
and contains 18 beds, with only 644 cubic feet of air space to each. 
Each room has 3 windows, a door and two beds, with 987 cubic feet 
to each bed. All these doors are 87X^1 inches, and the windows 
are 58X85 inches. 

The main building is 85 feet long and 35 feet deep. On the first 
floor are quarters for the resident medical officer, offices, dispensary, 
bath-room and water-closets. On the second floor is a ward contain- 
ing 8 beds, with 902 cubic feet to each ; 4 rooms, having 2 beds each, 
for sick officers, with 1200 cubic feet to each bed, and 2 rooms for 
nurses. The ward has 4 windows and 3 doors, and each room 3 
windows and a door. The windows are 87^X45} inches, and the 
doors 88X38 inches. 

In the wing are the main ward, 54X24 feet, and nurses* rooms 
and water-closets. The ward contains 18 beds with 17 17 cubic feet 
to each. It is lighted by 8 windows, each 76}X43 inches, and has 
4 doors 88iX47 inches each. The water-closets all have earthen 
jars under the seals, which are removed from the outside of the 
building every night. 

The grounds contain 1} acres, and are shaped somewhat like an 
arrowhead with blunted barbs. They are beautified with grass plots, 
trees, walks, and a pretty shaded mound 20 feet high. East of the 
wing is the residence of the medical officer in charge. 

The ventilation of this hospital is good, as the many windows and 
doors are assisted by the badly fitted woodwork. All the buildings 
and grounds are lighted by electricity. Water is obtained from a 
well, and by storing rain-water in large iron tanks. The well is 67 
feet deep, and furnishes an ample supply of water containing 13} 



NOTES ON NAVAL HOSPITALS. 289 

grains of solid matter to a gallon — silicic acid, chloride of sodium, 
carb. magnesium, sesquioxide of iron, and sulphate of calcium (trace). 
All drinking water is filtered, and in the summer months boiled. 
The rooms and wards of the main building have open fireplaces, but 
these being inadequate, stoves are employed. 

The staff consists of a surgeon and a passed assistant surgeon. The 
employes are the apothecary, watchman, two cooks, a gardener, and 
four coolies. Two of the coolies do the cleaning and act as nurses ; 
the other two are laborers. They have detached quarters. The 
watchman acts also as night nurse, and the cooks also set the tables. 
The gardener is also a carpenter and gatekeeper. The apothecary, 
in addition to usual duties, superintends nurses and issues stores. 

The daily average of patients last year was 10. The patients come 
entirely from the fleet, and many of the diseases originate on the 
coast of China. Venereal troubles, of course, play their part, 
diarrhoeal and malarial disorders are not uncommon, and smallpox is 
an occasional visitor. 

Yokohama itself furnishes a certain number of cases, as the vessels 
of the navy pass much of the year there, to escape the debilitating 
summer of the south. This city, frequently spoken of as a desirable 
sanitarium, has a delightful climate, though July and August have a 
mean temperature of 80 degrees F. with a minimum of 70 degrees F. 
January, the coldest month, has a mean of 38 degrees and a minimum 
of 30 degrees. The dew-point in January is 30, and in July and 
August is 70. The annual rainfall is 50 inches. The prevailing 
winds in May, June and July are southeast, and during the rest of 
the year northeast. The main portion of the city is intersected by 
numerous canals, and has northwest of it many rice fields which are 
frequently flooded. Malarial disorders are therefore common, but 
on the bluff this influence is not noticeable. 

Variola is present all the lime, and occasionally becomes epidemic, 
beginning among the native population. Rubeola, frequently attack- 
ing adults, is also occasionally epidemic. There is also a disease 
among the natives known as kakke, and considered identical with 

beri-beri. 

Closing Remarks. 

The subject is far from a conclusion. England, France and the 

United States are o\\\y three of the many nations who send their sons 

upon the sea as warriors. Austria, Brazil, China, Germany, Italy, 

-Russia, Spain, Turkey and others, represented by 2000 ships of war 



290 GROSSHEIM. 

with 200,000 men, have estabhshed naval hospitals well worthy of 
study. These institutions furnish a part of the histories of these 
countries and offer to him who seeks, much of interest and profit. 
Yet they cannot be considered here, as an apology is due for the 
many pages already written. This apology is found in the little 
attention these important hospitals have received from the various 
writers on that subject. 

Discussion. 

The Chairman. — The Section is very greatly obliged to Dr. 
Gatewood for this paper, which is valuable from an historical point 
of view, and for permanent consultation when published. The paper 
is accompanied with plans of a number of French, English, and 
American naval hospitals; and it would be very desirable if this 
could be completed for other nations, as Dr. Gatewood suggests, 
because, so far as I know, there is no treatise or article upon naval 
hospitals which is complete. 



UEBER MILITARLAZARETHE. 
Von Dr. Grossheim, 

Kbniglich Preussischer Generalarnt^ Berlin. 

Fiir die Erbauung und Einrichtung der Militarlazarethe miissen 
die grossen Grundsatze massgebend bleiben, welche sich fiir den 
Bau von Krankenhausern iiberhaupt durch die Anforderungen der 
in stetem Fortschritte befindlichen hygienischen Wissenschaft her- 
ausgebildet haben. Diese Anforderungen haben sich im Laufe der 
Jahre wesentlich gesteigert und einen erheblichen Aufschwung 
erfahren durch die fiir alle Zeiten denkwiirdigen Lazaret hbauten 
w'ahrend des nordamerikanischen Secessionskrieges, deren Beschrei- 
bung in dem iiberaus werthvollen Circular No. 6 des Generalstabs- 
arztes der Vereinigten Staaten-Armee vom 20. Juli, 1864, nieder- 
gelegt ist. 

Eine praktische Verwerthung und ausgezeichnete Weiterentwickel- 
ung jener Erfahrungen fallt bei alien seit jenen Tagen in Nordamerika 
entstandenen Krankenhausbauten dem fremden Besucher in ange- 



GROUND FLAN OF N^AL HOSPITAL. ^ARMODTH-SIO BEDS 

PLATE I. 



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ROYRL NnVHL HOSPITHL, YOKOHHMH. 




KEY TO PLATE II 



, », 3, 6. General Ward), 
. Gi>n-room and Engineer's Ward (roon 
I. Warfant Officers' Ward (rooms). 
I. Non-commissioned Officer*' Ward 

(rooms). 
. Contagious Ward. 
;. Ward-room Oifieflri' Ward (rooms). 
|. Mortuary. 
t. LMrine. 

i. Quarters for Natives. 



r;. General Cook and Bath House. 
. i8. Njrses' Quarters, Cfothing; Store, Coal 

Store and Larder. 
19. Steward's Quarters and Bedding Store. 
30. Dispensary, Survey Room, and Provision 

Store. 
91, 31. Senior Medical Officer's House. 
13. Second Medical Officer's House. 
35, Servants' Quarters, Kitchen, Stores, etc., 

(or Medical Officers. 
13. Contagious Ward, 
K. Kitchen, Disinfecting Rooms, etc. 



u 



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Basememt. 






KEY TO PLATE IV, 


Buraau o4 Pharmacy. 


^^. Baths. 


Offk« of Apothacary in.Chiel 


16, Laboratory. 


Laborstory. 


19. Grand Pharmacy. 


Mortuary Chapsl. 


30. Court. 


Anatomical Lecture Room. 


a 1 . Court 0I Sisters of Charity. 


Chemical Room, 


31 Lecture Room on Practice of Medicine 


Dissecting Room. 




Mineraloyical Room. 


34. Control. 


Botanical Room. 


aj. Office of Entries, 


Garden. 


ae Entrance 


Chemical Lecture Room. 


37. Guard Room, 


Dead Roam. 


96. Sentries' Room. 


Professor of Anatomy. 


39. Office of Director. 


Cu,»in«. 


30. Council Room. 


Linen Room. 


31, 3a, 33, 34. Rooms for arranging Lin tn 
35. Sleeping Room of Attendant*. 


Surgeon on Duty. 



PLATE V. 



^owouh JB6i^n/t€x//,ZaixZorv 



Z'^JStoiy. 




KEY TO PLATE V. 



1. Museum. 

2. Basins for Leachers. 

3. Lecture Room for Chemistry. 
. 4. Anatomical Collections. 

5. Ward. 

6. Water-closets. 

7. Ward. 

8. Ward. 

9. Ward. 

10. Water-closets. 

I I. Storeroom Pharmaceutical Utensils. 

12. Room for Confinement of Patients. 

13. Officers' Room. 

14. Court. 

15. Ward, Medical Clinic. 

16. Large Court. 



17. Ward. 

18. Court for Sisters of Mercy. 

19. Pharmacy for the Sisters. 

20. Chamber for the Sisters. 

21. Gallery. 

22. Office. 

23. Salle-a-Manger. 

24. Room for Pupils. 

25. 26. Superior Officer's Room. 
27, 28. Cabinet. 

29. Cabinet of Natural History. 

30. Library. 

31. Ward. 

32. Chapel of the Sisters. 

33. Room for the Sisters. 

34. Superintendence. 



PLATE VIII. 






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UEBER MIEITARLAZARETHE. 29I 

nehmster Weise ins Auge und alien denjenigen Mannern, welche 
thatig und erfolgreich an jener Entwickelung Theil genommen haben, 
gebiihrt daher innigster Dank. Insbesondere auch unserm Herrn 
Vorsitzenden, dem Surgeon John S. Billings, welcher mit einem 
seltenen technischen und arztlichen Scharfblick die Bediirfnisse fiir 
Krankenanstalten nicht nur in klassischer Weise formulirt, sondern 
auch die Erbauung solcher Musteranstalten energisch gefordert hat. 

Seiner geehrten Aufforderung entspreche ich heute, wenn ich 
einige Bemerkungen iiber Militarlazarethe vorzutragen mir erlaube, 
wobei ich mich schon aus RUcksicht auf die zu Gebote stehende 
Zeit im Allgemeinen nur auf die Verhaltnisse in der Deutschen 
Armee beziehen mochte. 

Zwei wichtige Zahlen konnen als hygienischer Markstein aus der 
Entwickelung des Deutschen bz. Preussischen Lazarethbauwesens 
an die Spitze gestellt werden. Erstens die Zahl, welche den fiir den 
einzelnen Kranken erforderlichen Luftraum bezeichnet und zweitens 
die Zahl, welche als Massstab fiir die Grosse des Lazareths einer 
Garnison zu Grunde gelegt werden soil, — die Normalkrankenzahl. 

Im Jahre 1852 schriebdasReglement fiir die Friedenslazarethe der 
Preussischen Arnaee vor, dass jedem Kranken ein Luftraum von 
450-540 Kubikfuss zu gewahren sei. Wer konnte heute noch eine 
solche Zahl als Norm fiir ein Krankenhaus festsetzen ? Das 3 und 
4-fache derselben wird nicht nur verlangt, sondern gilt iiberall fiir 
unerlasslich. So ist denn auch schon seit dem Jahre 1868 in der Preus- 
sischen Armee der Luftraum von 1200 Kubikfuss=37 Kubikmeter 
fiir jeden Kranken Vorschrift. Die seit diesem Jahr in den mannig- 
fachsten Lazarethen gemachten Beobachtungen haben die Ansicht 
gereift, dass dieser Luftraum als ausreichend erachtet werden kann, 
wenngleich zum Beispiel in den Isoiirpavillons, welche vorzugsweise 
zur Unterbringung fiir ansteckende Kranke dienen sollen, nicht 
selten iiber jenes Mass hinausgegangen wird. Die im Jahre 1891 
herausgegebene Deutsche Friedens-Sanitats-Ordnung enihalt dem- 
zufolge auch die Bestimmung, dass der normalmassige Luftraum fiir 
jeden Kranken durchschniltlich 37 Kubikmeter betragen soil. Und 
zwar sollen die mit horizontalen Decken versehene Krankenstuben 
in der Regel eine Hohe von 4 bis 4.20 Meter erhalten. Fiir jedes 
Bett ergiebt sich dann eine Grundflache von 9 bis 9.5 Meter. 

Was die Grosse der Stuben anbelangt, so sollen dieselben im 
Krankenblock nicht mehr als zwolf, in Pavilions nicht mehr als 18 
Betten erhalten. Neben diesen grossen Stuben sindin jedem Krank- 



292 GROSSHBIM. 

engebaude einige kleinere fur i bis 3 Kranke eingerichtet. Der 
Abstand der Betten von der Wand wird auf 0.5 bis 0.7 Meter, die 
Zwischenweite auf i Meter, der Gang zwischen den Fussenden 
zweier sich gegeniiberstehenden Reihen Betten auf 2 bis 2.5 Meter 
angenommen. Bei dieser Aufstellung ist vollkommen Platz zwischen 
den Betten vorhanden, um den zu jedem Bett gehorigen Kranken- 
tisch zu placiren und dem arztlichen Personal und den Pflegern freie 
Bewegung zu gestatten. 

£s ist ja bekannt, dass die angegebenen Masse betreffs der Hohe 
und der fur jedes Bett zu gewahrenden Bodenflache in einer Reihe 
von Krankenhausern iiberschritten werden, aber es muss gerade fiir 
Militarlazarethe daran festgehalten werden, nicht iiber das Noth- 
wendige und Bewahrte hinauszugehen. Ein Mass wie das in Preussen 
ubliche ist um so mehr ausreichend, als peinlich darauf gehalten wird^ 
dass alle unnothigen Mobel wie Utensilienstiicke und so weiter aus 
den Krankenzimmern fern gehalten werden und die Betten niemals 
mit Vorhangen versehen sind. 

Der Fussboden der Krankenraume besteht in der Regel aus 
einer Dielung von Kiefernholz, welche mit Oelfarbe gestrichen wird. 
Doch findet sich der Holzfussboden oft und namentlich in den nicht 
unterkellerten einstockigen Pavilions durch einen Belag von hart- 
gebrannten, glatten Thonplatten ersetzt, wobei zur Abhaltung der 
Bodenfeuchtigkeit und Verminderung der Abkiihlung eine Asphal- 
tirung auf flachseitigem Ziegelpflaster odereine Betonbettung erfolgt. 
Auch Riemenfussboden in Asphalt verlegt findet vielfach An- 
wendung. 

Dabei bleibt der Raum unter den Dielen hohl und wird einerseits 
durch Schlitze in den Fussleisten mit der Stubenluft, andererseits 
durch ein Thon- oder Metallrohr mit der Heizanlage in Verbindung 
gesetzt. 

Die Wande und Decken in den Krankenzimmern sind mit Oel- 
oder Lackfarbe gestrichen und zwar die Wandflachen gewohnlich 
in graugriinlichem, die Decken in mattweissem Tone. 

Die Fenster miissen moglichst hoch bis nahe an die Deckehinauf- 
gefuhrt werden, wahrend die Hohe der Fensterbriistung etwa 0.75 
Meter betragt. Sie sind meistens 1.2 Meter breit. Dabei gilt als 
Vorschrift, dass die Mindestflache fiir jedes Bett in den Kranken- 
blocks 1.2 bis 1.5 Quadratmeter, in den Pavilions auf 1.8 bis 2.3 
Quadratmeter ausmacht. Die Fliigelihiiren sollen eine Abmes- 
sung von nicht weniger als 1.5 Meter in der Breite und 2.5 Meter 



UEBER MtLITARLAZARETHE. 293 

in der Hohe haben. Die Heizung der Krankenzimmer erfolgt 
fast durchweg durch Kachel- oder eiserne Ocfen. Zentralheiziing 
ist nur ausnahmsweise bei neuren Anlagen vorhanden. Ob es 
vorzuziehen sei, alle Krankenzimmer mit Zentralheizung zu erwar- 
men oder bei der Einzelheizung durch Oefen zu bleiben, ist oft 
Gegenstand eingehender Erwagungen gewesen. Bis jetzt hat man 
sich fiir die Einzeloefen entschieden, einerseits weil dieselben nach 
den jahrelangen Erfahrungen den Ansprdchen durchaus geniigt 
haben, andererseits die laufenden Kosten fiir Kohlen und sonstiges 
Heizmaterial erheblich geringer sind. Die Oefen sind derartig ein- 
gerichtet, dass sie neben dem Heizzweck gleichzeitig der Ventilation 
dienen und sowohl zur Zufiihrung frischer Luft als zur Abfiihrung 
verdorbener Luft ausgenutzt werden. 

Ein besonderer Werth wird auf die Ventilationseinrichtungen 
gelegt, jedoch gleichzeitig grosste Einfachheit dabei beobachtet. 
Ein Luftwechsel von 60 Kubikmeter pro Bett und Stunde wird als 
angemessen erachtet und grundsatzlich angestrebt. Die Liiftungs- 
anlagen zur Erreichung dieses Zieles sind verschieden je nachdem 
es sich urn Krankensale in einstdckigen Pavilions oder um Kranken- 
stuben in Blocks handelt. Die Krankensale der Pavilions erhalten 
eine FirstlUftung entweder durch eine Anzahl von Luftschlotten, 
welche an der untern Miindung eine stellbare Verschlussklappe und 
iiber Dach einen Saugkopf erhalten, oder auch durch einen Dachreiter, 
welcher seitlich durch bewegliche stellbare Klappen verschliessbar 
ist. Wenn neben dieser Vorrichtung die Fenster geofTnet und die 
in der untern Thiirfiillung angebrachten durch Schieber verschliess- 
baren Schlitze benutzt werden, so kann man im Sommer einen ganz 
entsprechenden Luftaustausch bemerken. Fiir den Winter wird die 
frische Luft den Kranken durch einen Kanal zugefUhrt, welcher unter 
dem Fussboden verlauft und einerseits durch die Frontmauer hindurch 
nach aussen miindet, andererseits mit dem Raum zwischen Heiz- 
korper und Ofenmantel in Verbindung steht. In der Regel sind 
zwei Oefen vorhanden, von denen der eine der Aspiration der andere 
der Circulation der Luft dient. Den Abzug der verdorbenen Luft 
bewirken Liiftungsrohre, welche von dem Fussboden der Stube 
beginnend neben den Rauchrohren befindlich und iiber Dach mit 
einem Saugkopf versehen sind. 

In den Krankenstuben der Blocks sind Liiftungsrohre angebracht, 
welche zwei mit stellbarem Verschluss versehene Oeffnungen haben. 
Von diesen wird die oberc, unter der Zimmerdecke befindiiche fiir 



294 GROSSHEIIf. 

den Gebrauch im Sommer, die untere, dicht iiber den Fussboden 
befindiiche f iir den Gebrauch im Winter, offen gehalten. Der Ofen 
saugt auch hier im Winter durch einen Kanal frische Luft an. 

Einen wesentlichen Fortschritt gegen fruher hat die Beleuchtung 
gemacht, insofern in einer grosseren Anzahl von Lazarethen elek- 
trische Beleuchtung eingef iihrt ist. Bei alien Neubauten.wird dieser 
Beleuchtungsart mit Recht den Vorzug gegeben. In den Kranken- 
stuben sind GlUhlichtflammen von 12-20 Kerzenstarke, auf den 
Hofen Bogenlicht in Gebrauch. 

Ich habe diesen kurzen Ueberblick iiber die Haupteinrichtungen, 
welche fiir einen Krankenraum eines Militarlazareths in Betracht 
kommen, zusammengefasst, ohne bisher auf das eigendiche System, 
in welchem ein solches Lazareth zu erbauen ist, eingegangen zu 
sein. 

Die Frage nach dem System hangt innig zusammen mit der zwei- 
ten oben als Markstein in der Entwickelung der Militarkrankenhauser 
bezeichneten Zahl, mit der Normalkrankenzahl zusammen. Der 
Umfang eines Garnisonlazareths wird nach der Garnison-Kopfstarke 
und der zu erwartenden Krankenzahl derselben bemessen. In dem 
alten Lazareth- Reglement von 1852 wurden 6i Prozent dieser Kopf- 
s&rke — also 15 von 100 — als krank und der Lazarethpflege bediirftig 
angenommen und demgemass zum Beispiel die Grosse eines Laza- 
reths fiir eine Garnison von 4500 Mann auf 300 festgestellt. 

Inzwischen haben sich die Mortalitatsverhaltnisse ausserordentlich 
gebessert. Der Generalstabsarzt der Preussischen Armee, Seine 
Exzellenz von Coler, dessen hohe Verdienste um das Armeesaniiats- 
wesen Ihnen bekannt sind, konnte in einer am Stiftungstage des 
medizinisch-chirurgischen Friedrich Wilhelms-Instituts in Berlin 
gehaltenen Rede als einen glanzenden Erfolg der auf die Verbesserung 
der Gesundheitsverhaltnisse im Heere gerichteten, unermiidlichen 
und sachverstandigen Bestrebungen hervorheben, dass „in dem 
20-jahrigen Zeitraum von 1868-1887 die Zahl der jahrlichen 
Gesammterkrankungen in der Armee um 46 Prozent herabgesunken 
und die jahrliche Sterbeziffer von 6.9 Prozent auf 3.2 Prozent sank, 
was eine Verminderung um 54 Prozent bedeutet. An Typhus hatte 
das Heer im Jahre 1868 einen Zugang von 10.9 auf 1000 der Kopf- 
starke, im Jahre 1887 nur 4.4, also um mehr als die Halfte weniger, 
und der Verlust des Heeres durch Tod in Folge dieser Krankheit 
verringerte sich wiihrend dieses Zeitraumes in stetiger Abnahme von 
2.1 Prozent auf 0.32 Prozent. also auf nahezu \ der friiheren Hohe. 



UEBER MILITARLAZARETHE. 295 

Durch den gering^en Krankenzugang sind im Jahre 1887 verglichen 
mit den entsprechenden Verhaltnissen des Jahres 1868 allein 2,cxx),- 
cxx> Behandlungstage weniger erforderlich gewesen und, was viel- 
mehr ins Gewicht fallt, die allmahlich erzielte Verminderung der 
Sterbeziffer in der Armee bedeutet allein fiir das Jahr 1887 einen 
Gewinn von 1539 Mann, die in diesem Jahre dem Heere,dem Staate 
und ihrer Familie erhalten sind." 

Diesen Ausfiihrungen entspricht die hochst bemerkenswerthe 
Thatsache, dass die Normalkrankenzahl, das heisst, wie oben 
bemerkt, die Zahl der fiir den Bau eines Lazareths in Aussicht zu 
nehmenden Krankenzahl, von 61 Prozent der Kopfstarke allmahlich 
herabgeselzt werden konnte, so dass sie jetzt nur 4 Prozent der etats- 
massigen Garnisonkopfstarke betragt und in gUnstig gelegenen Gar- 
nisonen sogar auf 3} Prozent sinkt. Um bei dem obigen Beispiel zu 
bleiben, werden also bei einer Kopfslarke von 4500 Mann — nicht 
mehr wie ehedem, fiir 300 Kranke, sondern nur fiir 180 Kranke 
Lazaretheinrichtungen zu treffen sein. Welche unendlichen Vortheile 
sich aus diesem Zahlenverhaltniss ergeben, liegt auf der Hand. Ks 
bedeutet — abgesehen von dem daraus fiir die Gesundheit der Trup- 
pen hervorleuchtenden giinstigen Zeugniss — nicht nur eine ausseror- 
dentlich wichtige Ersparniss an Aniage- und Unterhaltungskapital, 
sondern auch eine erheblicher Entlastung des arztlichen und Verwal- 
tungs-Personals. 

Es sei iibrigens ausdrUcklich bemerkt, dass diese Normalkranken- 
zahl bei der thatsachlichen Belegung der Lazarethe durchaus nicht 
immer erreichtwird, sondern dass ausreichend Raume zur Verfiigung 
stehen, um einen steten Wechsel in der Belegung der einzelnen 
Krankenraume vorzunehmen. Ein solcher Wechsel ist ausdriicklich 
vorgeschrieben und muss auf einer in jedem Krankenzimmer han- 
genden Tafel durch Notirung iiber die Belegungszeiten ersichtlich 
gemacht werden. Auch ist eine vollstandige Isolirung ansteckender 
Kranken bei der nach obigem Massstab festgesetzten Lazarethgrosse 
durchfiihrbar. 

Von der Grosse des zu erbauenden Lazareths hangt das System 
ab, nach welchem es errichtet werden soil. Wirunterscheiden Block- 
system und das Pavillonsystem. 

Unter Krankenblocks verstehen wir, wie bekannt, Gebaude von 
einem oder mehreren Geschossen, in denen die miteinander nicht 
verbundenen Krankenstuben an einem gemeinschaftlichen Langs- 
flur liegen, wahrend wir als Pavilions Gebaude von einem Geschoss 



296 GROSSHEIM. 

Oder von zwei Geschossen mit grosseren die ganze Tiefe des Gc- 
baudes einnehmenden, von einem Vorraum oder Mittelbau zugang- 
lichen Krankensalen bezeichnen. Bei kleineren Lazarethen wird 
noch gelegentlich ein Krankenblock gebaut, in dessen unterem Ge- 
schoss die Verwaltungsmume liegen, doch wird auch f iir diese schon 
vielfach das System der eintstockigen Pavillonbauten fur die Kran- 
kenunterkunft gewahlt und fiir die Verwaltung ein besonderes kleines 
Gebaude errichtet. 

Fiir grossere Anlagen wird je nach dem klimatischen und sonsdgen 
lokalen Verhaltnissen entweder der Bau von zwei- und einstockigen 
Pavilions in Verbindung mit Verwaltungsgeb'auden oder das gemischte 
System, das heisst, theils Blocks theils Pavilions fiir die ^ranken- 
unterbringung gewahlt. Als Beispiele fiir solche Bauten gemischten 
Systems darf ich aus neuester Zeit die Lazarethe in Mainz, Potsdam, 
Stettin nennen, wahrend Ihnen ja aus friiheren Jahren das Garnison- 
lazareth Tempelhof bei Berlin, welches immer noch als mustergiiltig 
dasteht, bekannt ist. Als Lazarethbau, welcher nur aus einstockigen 
Pavilions besteht, sei das in neuester Zeit vollendete Lazareth in 
Strassburg angef iihrt. 

Auf eine nahere Beschreibung der Anordnung und sonstigen Ein- 
richtung der Gebaude, hier einzugehen, wiirde zu weit fiihren. 
Erwahnt sei aber, dass abgesehen von modernsten Wasch- und 
Kiicheneinrichtungen, insbesondere die Einrichtung von Operations- 
zimmern, sowie die Beschaffung von Desinfektionsapparaten und 
transportablen Lazareth baracken eine grosse Beracksichtigung 
erfahren hat. 

Fiir die Operationszimmer wird selbstredend verlangl, dass sie 
alien Anspriichen, welche die anti- bz. aseptische Wundbehandlung 
erfordern, in vollstem Umfange entsprechen. In Folge dessen wer- 
den Fussboden und Wande aus glattem, undurchlassigen, leicht zu 
reinigenden Material hergestellt, alle zur Ablagerung von Keimen 
geeigneten Ecken und Vorspriinge vermieden und alles der pein- 
lichsten Reinigung zuganglich gemacht. Die Ausstattung mit 
Operationstisch, Instrumentenschranken und so weiter erfolgt in 
demselben Sinne. 

Die Desinfektionsapparate arbeiten mit stromendem gesattigten 
Wasserdampf von mindestens 100° C. und sind entweder mit einer 
fiir sonstige Zwecke schon im Lazareth vorhandenen Dampfma- 
schine in Verbindung gesetzt oder haben ihre eigenen Dampfent- 
wickler. Es sind mit der Zeit eine ganze Anzahl von Fabriken mit 



UEBER MILITARLAZARETHE. 29/ 

der Anfertigung solcher Apparate hervorgetreten, die bekanntesten 
sind Rietschel und Henneberg in Berlin, Schimmel und Co., in Chem- 
nitz, Budenberg in Dortmund, Schmidt in Weimar, Rohrbeck in 
Berlin und Andere. Die Apparate miissen so geraumig sein, dass 
Matratzen und grosse Packete von Kleidem, Wasche und so weiter 
leicht darin Platz finden, und dass sie namentlich auch fur die 
schnelle Desinfektion grosserer Mengen von Uniformstiicken der 
Truppen brauchbar sind. 

Transportable Lazarethbaracken, denen eine unschatzbare Wich- 
tigkeit fiir die Militarkrankenpflege im Frieden und im Kriege 
beizulegen ist, sind in grossem Umfange ftir die Preussische Armee 
beschafft und haben sich ganz vortrefflich bewahrt. Sie gewahren 
im Sommer und Winter den Kranken einen sehr angenehmen 
Aufenthalt und eignen sich in jeder Beziehung ausgezeichnet zur 
Krankenunterkunft. Sind sie schon bei stehenden Lazarethanlagen 
fiir gewohnliche Verhaltnisse zur Isolirung der Kranken von grossen 
Nutzen, so gewinnen sie zu Zeiten von Epidemien und zu Kriegs- 
zeiten eine ganz ausserordentliche Bedeutung. Sie sind iiberall hin 
schnell versendbar und leicht auch von ungeiibten Handen aufstell- 
bar, dabei sowohl fiir Krankenunterbringungs- als fiir Lazareth- 
Wirthschaftszwecke treflflich verwendbar. Beim Garnisonlazareth 
Tempelhof (Berlin) war vom Juli bis Ende Dezember 1891 eine 
voUstandige Lazarethanlage aus transportablen Milit'arlazareth- 
baracken eingerichtet, mit Kranken belegt und dauernd in Betrieb 
gesetzt. Die dabei gewonnenen Erfahrungen waren glanzende und 
sprachen in jeder Beziehung fiir die Brauchbarkeit der Baracken. 
Eine kurze Beschreibung derselben ist in der Deutschen Friedens- 
Sanitats-Ordnungvon iSgienthalten; ausf iihrlicher und ausgehender 
finden sie sich in dem weltbekannten Werke „die transportable 
Lazarethbaracke von von Langenbeck, von Coler und Werner" 
geschildert. Vielleicht tragt dieser Hinweis auch dazu bei, die Ver- 
breitung und Verwendung transportabler Baracken in der Kranken- 
pflege, namentlich auch seitens kleiner, pekuniar nicht sehr 
leistungsfahiger Gemeinden zu fordern. Ich mochte Ihre Geduld 
aber nicht langer in Anspruch nehmen. Wenngleich ich mir bewusst 
bin, wichtige Punkte fiir den Bau und die Einrichtung von Militar- 
lazarethen nur ganz oberflachlich gestreift und viele ganz iibergangen 
zu haben, darf ich doch der Besprechung eine weitere Ausdehnung 
nicht geben und nur noch zum Schlusse hervorheben, dass die Mili- 
tarlazarethe in Deutschland unter dem Befehle und der Verwaltung 



298 STONER. 

von Chefarzten stehen und sich unter diesem Befehle in erfreulich- 
stem Zustande befinden. Nur der Arzt ist im Stande die Bediirfnisse 
eines Krankenhauses voll zu wiirdigen und den ganzen Kranken- 
hausdienst, der kein anderes Ziel kennt, als den Verwundeten und 
Kranken die bestmoglichste Pflege zu sichern und ihrer baldigen 
Genesung zuzufuhren, fachgemass zu leiten. 



THE UNITED STATES MARINE HOSPITAL SERVICE. 
By George W. Stoner, M. D., Surgeon, U. S. M. H. S., 

Baltimore^ Maryland, 

The Marine Hospital Service is not quite as old as the Declaration 
of Independence, the adoption of the Constitution, or the establish- 
ment of the government of the United States, but it has already 
reached a very respectable age and is fast approaching its cen- 
tennial. 

England had a marine hospital at an earlier date, the celebrated 
Greenwich Hospital, but this was essentially a military institution, 
established for the benefit of seamen of the Royal Navy. The marine 
hospital service of the United States was established, or rather provi- 
sion for its establishment was made by act of Congress approved 
July 16, 1798. By this act Congress imposed a tax of twenty cents a 
month on every seaman employed on foreign or coasting vessels of 
the United States, and out of the moneys collected by authority of 
this act, the President of the United States was authorized to furnish 
temporary relief to sick and disabled seamen, the moneys to be 
expended in the districts >yherein collected. This, however, was 
amended the following year, March 2, 1799, by an act authorizing 
the expenditure of hospital money within any part of the State where 
collected, or in the State next adjoining. An amendment was also 
passed at this time extending the operations of the law so as to 
include the officers and seamen of the navy.* The sentiment that 
led up to the passage of the act establishing the marine hospital 
service was forcibly expressed by the Boston Marine Society in a 
petition as early as 1791 ; and in the House of Representatives, 

*In the year 181 1 separate hospitals were established for the navy. 



THE UNITED STATES MARINE HOSPITAL SERVICE. 299 

November 19, 1792, in his speech on the improvement of commerce, 
the Hon. Mr. Williamson said : 

" Wherever it is probable that sailors may be sick, there I would 
make provision for their support and comfort. Hospitals should be 
erected or lodgings hired, as the case may be, at every port of entry 
in the United States, for sick and infirm seamen, where they may be 
properly attended during their indispositions. The money to be col- 
lected at the several ports as hospital money should be expended at 
such port and no other place, under the care of such person as may be 
designated for that purpose. Let a small deduction be made from 
the wages of every seaman, to be paid at the several ports of entry 
for their use. I have mentioned a deduction from their wages, 
because this mode of raising money would probably be more accep- 
table, and because it is the most equitable tax that can be levied.** * 

Hospital treatment or its equivalent was given to sick and disabled 
seamen by the marine hospital service in Boston as early as 1799, the 
year following the establishment of the Service. The first marine hos- 
pital owned by the government, and established under the act of 1798, 
was located at Washington Point, Norfolk County, Virginia. It was 
purchased by the United States in 1800. Three years later, in 1803, 
a marine hospital was completed for the port of Boston. It was 
located at Charlestown on the Mystic river, an appropriation of 
fifteen thousand dollars having been made for the purpose by act 
of Congress approved May 3, 1802. By this act the money collected 
for the benefit of sick and disabled seamen was constituted a gen- 
eral fund ; and provision was also made for the establishment of the 
marine hospital service at New Orleans (not then belonging to the 
United States). The following is the text : 

'* That the moneys heretofore collected in pursuance of the several 
acts for the relief of sick and disabled seamen, and at present unex- 
pended, together with the moneys hereafter to be collected by 
authority of the before-mentioned acts, shall constitute a general fund, 
which the President of the United States shall use and employ as 
circumstances shall require, for the benefit and convenience of sick 
and disabled American seamen: provided^ that the sum of fifteen 
thousand dollars be, and the same is hereby appropriated for the 
erection of an hospital in the district of Massachusetts." 

Section 2. The President is authorized to cause such measures to be 
taken as, in his opinion, may be deemed expedient for providing 

* Hamilton, Appleton*i Cycloptzdia^ 1879. 



i 



300 STONER. 

convenient accommodations, medical assistance, necessary attendance 
and supplies for the relief of sick and disabled seamen of the United 
States who may be at or near the port of New Orleans, in case the 
same can be done with the assent of the government having juris- 
diction over the port. 

Section 3 required masters of boats, rafts, etc., going to New 
Orleans down the Mississippi to render true accounts of the number 
of persons employed on board, and imposed a tax of twenty cents a 
month for every person so employed, which sum the master was 
authorized to retain out of the wages of such person. 

Section 4 authorized the President to apppint a director of the 
marine hospital at New Orleans. 

Section 5 authorized the admission of sick foreign seamen into 
marine hospitals of the United States upon certain conditions, and 
fixed the rate of charge at seventy-five cents a day. 

The following letters from American state papers quoted by 
Supervising Surgeon-General Hamilton, in a paper read at the annual 
meeting of the National Board of Steam Navigation, held at Cairo, 
Illinois, several years ago, also in his article in Appleton's Annual 
Cyclopaedia, show, as he says, *' the state of affairs which rendered 
action on the part of Congress necessary ** : 

**New Orleans, August 10, 1801. 

A great number of American citizens, especially seamen and boatmen from 
the Ohio, die here yearly for want of a hospital into which they might be put 

I and taken care of; not that they are refused admittance into the Spanish Poor 

Hospital, but that building is by much too small for the purpose, 
r No public house of any reputation will take them in, and consequently they 

I lie in their ships or boats or get into wretched cabins, in which they die mis> 

I erably, after frequently subjecting the humane among their countrymen to much 

trouble and expense. Will not this be an object, sir, worthy the attention of 
the government of the United States? And might not a fund be easily estab- 
lished for the preservation of these poor people, by imposing a light tax upon 
every vessel and boat that comes in as well as upon every seaman and boatman ? 
About two hundred vessels have entered here from sea during the twelve 
I months past, and allowing eight men only to each, it makes 1600. Perhaps 

I from 350 to 400 boats have come down from the Ohio, etc., during the same 

I time, and allowing four men to each, it would make about an equal number of 

men. A small sum from each, added to something from every vessel and boat, 
; would probably produce a capital equal to the exigency. 

j (Signed) Evan Jones." 



I 



THE UNITED STATES MARINE. HOSPITAL SERVICE. 3OI 

E. M. Day, Esq., in a letter addressed to the Secretary of State, 
dated November 8, 1802, said: " It will readily occur to you, sir, 
that thousands of our fellow-citizens must soon be employed in navi- 
gating the ships and boats which must ever be used as the means of 
transporting these commodities (those of the western country) from 
one place to another. Now, sir, when we take into consideration the 
climate and the season of the yefir when this commerce must be 
carried on, the risk to our citizens must be multiplied in a high 
degree. It is well known that the western rivers cannot be conveni- 
ently navigated into the Mississippi until the breaking up of the frost 
in the spring of the year. It is then that the great river begins to 
rise, and it generally remains up until July. The great distance and 
unavoidable impediments naturally in the way always carry over 
these commercial transactions to so late a period as to leave the great 
bulk of those employed in them at or about New Orleans in the 
sickly season of the year, which in that low, flat, unhealthy southern 
climate is fatal in the extreme to the strong, robust constitutions of 
our western brethren ; hence many of them fall victims to climate 
and disease, leaving families and friends at a great distance from 
them. The want of proper accommodations for sick and infirm seamen 
and boatmen at New Orleans is another very serious inconvenience 
our poorer class of fellow-citizens are much subjected to in that place. 
It is really pitiable to see such numbers of distressed objects as some- 
times present themselves to view in the sickly months, who have been 
left to shift for themselves, after their employers have made their 
markets. Something like an hospital establishment, to be superin- 
tended by American physicians, would go a great way to alleviate 
the distresses of those useful men. I mentioned American physicians 
because our people are strongly prejudiced against those of the 
Spanish faculty ; and generally not understanding the language, they 
derive little or no benefit from them.** 

The first U. S. marine hospital at New Orleans was not erected 
until a number of years later, but provision was made for the care of 
sick and disabled seamen in the local hospitals as early as 1804, 
and a physician appointed to look after their welfare, the same as had 
been done originally in Boston, and which is now (since the reorgan- 
ization of the Service) the custom at the smaller ports of the country, 
that is to say where the Service is not large enough to warrant the 
assignment of a regular medical officer or the establishment of a 
station of the first class. 



302 



STONEK. 



For a number of years after the establishment of the Service the 
expense had to be met out of the fund created by the tax upon sea- 
men, and as the amount collected was not sufficient to meet the 
demands, restrictions were from time lo time necessary lo keep the 
expenditures within the available fund. Chronic and incurable cases 
were excluded from the benefits of the Service, and in no case was 
relief allowed for a longer period than four months. 

Patients in some ports were cared for in local hospitals and were 
(armed out to the lowest bidders, and in places where there were no 
hospitals medical charges were restricted lo twenty cents a day, with 
boardin)^, lodgings, nursing and washing at two dollars and fifty 
cents a week. For districts south of the Potomac an addition of 
twenty per cent was allowed. The hardships atlendmg the life of 
seamen and the administration of the fund for the relief from this 
period were set forth by the late Supervising Surgeon-General Wood- 
worth in the following language (Annual Report, 1872); 

" It was claimed that the fund was lo be considered as auxiliary to 
the provision made by the municipal authorities, rather than as a full 
compensation for the relief which was due to the wants of sick and 
disabled seamen. In view of the inadequacy of the fund, a more 
liberat ruling was impracticable. The administration of the fund on 
this principle worked ihegreaiesi hardships in the new cities and towns 
which sprang up on the banks ol the western lakes and rivers, where 
few accommodations were to be had for the care of sick strangers left 
helpless upon their shores. Those who engaged in the commerce of 
ihe western rivers were subjected lo climatic changes thai were to 
them very pernicious. The numbers who perished in the long 
descending voyages of the flat-bottomed boats which left the upper 
waters of the Mississippi and its tributaries, in summer and early 
autumn, to find a market for the fruits of iheir toil, at New Orleans 
were very great. Nothing was more common than for two out of 
five hands who generally managed those boats to die, and it some- 
times happened that the whole crew perished from disease and that 
the boat with its cargo was left deserted. The steamboats ascending 
the Mississippi and its tributaries brought up every year a great 
number of deck passengers, chiefly the sons of farmers returning 
from their fi.ttbuat voyages, many of whom died on board, while 
others were left on shore at the river towns helpless and among 
strangers. The cholera epidemic of 1832 and 1834. added greatly to 
the catalogue of their ills. Moved by a feeling of common humanity 



I 





THE UNITED STATES MARINE HOSPITAL SERVICE. 3O3 

for the large class of our young men who had surrendered the 
endearments of a life spent at home, and united their fortunes with 
strangers by embarking in the more daring, precarious and toilsome 
interests of commerce — a pursuit, more than most others, beset with 
temptations to risk of health and life, to recklessness of character and 
insensibility to future wants, — sensible also of the sufferings attendant 
upon such an improvident life, whole communities, both on the sea- 
board and in the interior districts, petitioned Congress for additional 
appropriations and the enactment of laws providing increased facili- 
ties for the relief of this unfortunate class. From one port it was 
reported that no better place could be offered to sick seamen than the 
warehouses and the deserted tenements along the wharf; from another, 
that they had to be sent to the city almshouse, which was also con- 
nected with the penitentiary for common vagrants and petty convicts ; 
and from another the sad story was told that seamen, sick with 
various diseases, cholera, smallpox, etc., were often forced promiscu- 
ously into the same chamber, where the dying and the dead were 
alike neglected." 

Beginning in Boston in 1799, the Service was soon extended to the 
principal ports along the Atlantic coast, and gradually, as Congress 
made special appropriations for the same, marine hospital buildings 
were erected at other ports than those already named. The expenses 
attending the erection of the original hospitals at Norfolk and Boston 
were defrayed from the marine hospital fund (the tax collected from 
seamen for their relief when sick and disabled) in accordance with 
the law of 1798, which also provided ** that when there should be a 
sufficient surplus after defraying the expenses of temporary relief to 
seamen, it should be used in erecting marine hospitals." This pro- 
vision was made probably in view of another provision of the same 
act, which authorized the President to receive donations of personal 
property or real estate and which contemplated a surplus. During 
the earlier years of the Service there was occasionally a small surplus, 
more frequently a shortage ; and as years went on the expenses were 
greatly increased, and entirely out of proportion to the increase of the 
collections, and Congress was called upon to make necessary appropria- 
tions to meet the difference. These appropriations varied in amounts 
from one thousand dollars to two hundred and seventy-five thousand 
dollars a year, and up to 1873, when the last appropriation was 
made, amounted to the sum of $4,830,994.34. The collections during 
the same period footed up the amount of $7,096,968.89, making a 



304 



la] of $1] 



7.963-z 



while the expendiP 



e $11,639.- 



n favor 



le 
)r 

m 



ditures were | 
934.66, leaving at the dose of the fiscal year 1873 a balance ii 
of the fund amounting to $288,0 

In the year 1837 (act approved March 3, 1837) Congress appro- 
priated seventy-five thousand dollars for ihe erection of a i 
hospital in the city of Mew Orleans, and for the purchase of lands a 
which to erect said marine hospital. 

The President was also aiiihorized to select and cause to he pupi 
chased for the use and benefit of sick seamen, b 

navigators on the western rivers and lakes, siiilal)le sites lor marine ' 
hospitals, provided that the number thereof shall not exceed for the 
Mississippi river three, for the Ohio three, and for Lake Erie t 
By this same act the collection of hospital lax was suspended for 
one year, and instead of said tax ihe sum of one hundred and fifty- 
thousand dollars was appropriated. A later act (August 29, 1842^! 
confirmed the act of 1837 and authorized the purchase of sites for* 
marine hospitals at Natchez, Miss., Napoleon, Ark., St. Louis, Mo., 
Paducah, Ky.. Louisville. Ky., Pittsburg, Pa., Cleveland, Ohio. An 
appropriation for the erection of the first marine hospital in Chicago 
was made by act of Congress approved August 3, 1848, and n 
located on land adjacent to old Fort Dearborn. The second, the 1 
present hospital in Chicago, was erected under authority of act oC J 
Congress dated June 30, 1864, and located on the lake shore, aboid 
five miles north of the harbor. The land was not purchased, how- 
ever, until 1867. The building was completed and ready for the] 
reception of patients in 1873, *"<! was pronounced "the finest struo^J 
ture of its kind in the country, far superior to the marine hospitals j 
hitherto constructed." Before this building was completed, however),! 
the Supervising Surgeon-General (the late Dr. Woodworth) " 
lieved that one-fourth of the amount required to complete the build- 
ing and fit it for occupation would have been sufficient to construct 1 
a hospital which would meet the wants of the Service equally well." i 
He then evidently had in mind the pavilion which was subsequently I 
adopted, and has been continued up to this time as the style of marine j 
hospital construction. He was in "favor of constructing all the j 
hospitals of wood, and destroying them after ten or fifteen years, both I 
as a sanitary and an economical measure, and building new ones ii 
iheir stead." Fire is no doubt the best and surest antiseptic, but in ] 
these days of medical progress less heroic measures answer every J 
purpose, and if buildings are properly constructed, drained and 1 



THE UNITED STATES MARINE HOSPITAL SERVICE. 3O5 

ventilated, the torch need never be applied. The erection of the 
marine hospital at Detroit, Michigan, was authorized by an act of 
Congress dated August 4, 1854. This same act also made appro- 
priations for the construction of marine hospitals at Burlington, Iowa, 
Pensacola, Fla., and for the second hospital at New Orleans. The 
marine hospital at Detroit is a three-story and basement solid brick 
building, constructed somewhat after the Mills style of architecture, 
except that the ground plan is in the shape of the letter T instead of 
^H, and differs in this respect from all or nearly all other marine hos- 
pitals the plans of which were drawn by Robert Mills, architect, in 
the year 1837, and followed by the government, without material 
change, for a period of about thirty years, or until the construction 
of the imposing structure previously referred to designed by the late 
A. B. Mullet and located in this city (Chicago). 

The marine hospital service on the Pacific coast was first estab- 
lished at San Francisco in 1851 (the contract system), and a U. S. 
marine hospital was in use at that port in 1854. It was large and 
well built, but was injured by an earthquake in 1868. The contract 
system was then resumed, and continued until the completion of the 
present pavilion hospital. Besides the places already named, hos- 
pitals were located before the reorganization of the Service at Mobile, 
Ala., Charleston, S. C, Portland, Me., Ocracoke, N. C, Evansville, 
Ind., Vicksburg, Miss., St. Marks, Fla., Burlington, Vt., Wilmington, 
N. C, Galena, 111., and Port Angelas, Washington Territory. Most 
of these buildings were large, substantial structures, erected at great 
expense, and some of them were sold afterward at a great reduction, 
especially those built at places where they were not needed at all, as 
for example at Paducah, Ky., Burlington, Iowa, Galena, Illinois, and 
Burlington, Vermont. During the war of the Rebellion many of 
the marine hospitals north and south were used as military hospitals, 
and the hospitals at Norfolk and Boston were in similar use during 
the war of 181 2. 

The marine hospital service was reorganized in pursuance of an 
act of Congress approved June 29, 1870: **An Act to reorganize the 
Marine Hospital Service, and to provide for the relief of sick and 
disabled seamen. Be it enacted, etc. 

" That from and after the first day of August, eighteen hundred 
and seventy, there shall be assessed and collected by the Collector 
of Customs at the ports of the United States, from masters or owners 
of every vessel of the United States arriving from a foreign port, or 



306 STONER. 

of registered vessels employed in the coasting trade, the sum of 
forty cents per month for each and every seaman who shall have 
been employed on said vessel since she was last entered at any port 
of the United States, which sum the said master or owner is hereby 
authorized to collect and retain from the wages of said employees." 
Section 4 of this act required that all moneys received or collected by 
virtue of this act shall be paid into the treasury like other public 

• 

moneys, without abatement or reduction, and appropriated all moneys 
so received for the expense of the marine hospital service and to 
the credit of the marine hospital fund. Section 5. — That the fund 
thus obtained shall be employed under the direction of the Secretary 
of the Treasury, for the care and relief of sick and disabled seamen 
employed in registered, enrolled and licensed vessels of the United 
States. Section 6. — "And be it further enacted, that the Secretary of 
the Treasury is hereby authorized to appoint a surgeon to act as 
Supervising Surgeon of Marine Hospital Service, whose duty it shall 
be, under the direction of the Secretary, to supervise all matters con- 
nected with the marine hospital service, and with the disbursement 
of the fund provided by this act, at a salary not exceeding the rate of 
two thousand dollars per annum and his necessary traveling expenses, 
who shall be required to make monthly reports to the Secretary of 
the Treasury.** 

The office of Supervising Surgeon was first filled in April, 187 1, by 
the appointment of Dr. John M. Woodworth, of Illinois. The work 
of reorganization was commenced at once, and had so far progressed 
by the end of the fiscal year 1872 that the Supervising Surgeon (Dr. 
Woodworth) in his annual report for that year was enabled to show a 
** marked increase in the facilities for affording relief, a considerable 
decrease in the per diem cost for the care of each patient,'* and an 
actual saving to the government of $56,819.31 as compared with the 
preceding year. In the original work of reorganization, or rather in 
anticipation of the law reorganizing the Service and before a super- 
vising surgeon was appointed, the Secretary of the Treasury received 
valuable aid from Surgeon John S. Billingsiof the army (the distin- 
guished chairman of this Section). Twelve thousand three hundred 
and two sick and disabled seamen were furnished hospital relief during 
the year 1872, and by a system of outdoor or dispensary relief inaugu- 
rated this year, eight hundred and fifty-four seamen were furnished 
medicine, making a total number of thirteen thousand one hundred 
and fifty-six. It need hardly be added that the Service soon became 



THE UNITED STATES MARINE HOSPITAL SERVICE. 307 

self-sustaining and that no appropriation was received or required 
after the year 1873, except for the erection of new hospital buildings. 
The work of reorganization had now fairly begun. Surgeons and 
assistant surgeons, after passing a satisfactory examination before a 
board of surgeons, were appointed by the Secretary of the Treasury 
on the recommendation of the supervising surgeon. Hospitals were 
divided into two classes, viz : Class i. United States Marine Hos- 
pitals. Class 2. Local Hospitals, where seamen were received at rates 
authorized by the Department. 

Provision was also made for the care of sick and disabled sea- 
men at ports where there were no hospitals. One medical officer was 
assigned to duty at each hospital (Class i)as surgeon in charge, and 
when an assistant surgeon was also assigned at the same station, one 
of the two was required to be on duty at the custom-house during 
business hours, to examine applicants for admission to hospital, 
to issue a permit if necessary, to prescribe for cases not requiring 
treatment in hospital, and at the same time to guard the Service 
against the irregularities and abuses which had formerly crept in and 
made the reorganization necessary. At the hospitals of Class 2 
where the Service was large enough to warrant the assignment of a 
medical officer, his duties were essentially the same as if on duty at 
the custom-house office or dispensary of a station of Class i ; and he 
was also required to inspect the hospitals where seamen were 
admitted and to supervise all matters relating to the Service at the 
port. At the smaller ports the customs officer was authorized to 
provide for the care of sick seamen by arrangement with a local 
physician, or to furnish transportation to the nearest hospital vhere 
provision was made for relief. The surgeon in charge of a marine 
hospital was given authority over all officers and employes of the 
hospital, and he was empowered to enforce regulations for the man- 
agement of the hospital, subject to the approval of the supervising 
surgeon. He was held responsible for the proper and economical 
administration of the hospital under his charge, and for the care and 
preservation of the building, furniture and stores, but he was not 
entitled to any stores (subsistence supplies) for himself. He was 
required (as he is now) to supply subsistence for himself and family, 
and household help. The steward and other employes were (as they 
are now) subsisted by the hospital. The compensation of all officers 
and employes of the Service (except the supervising surgeon, whose 
salary was fixed by act of Congress) was fixed by the Department. 



f 

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308 STONER. 

Regulations covering the foregoing and all other requirements 
of the Service and duties of medical officers were issued in book form 
during the latter part of the year 1873, and these regulations have 
served as the basis and model upon which all subsequent regu- 
lations, made necessary by later acts of Congress or Department 
decisions, have been framed. Within three years after its reorganiza- 
tion the work of the Service began to attract attention from abroad. 
The London medical journals were profuse in their praise of this 
peculiarly American institution. The Lancet recommended that a 
" leaf be taken out of the book of the Marine Hospital Service of 
the United States/* and remarked that *' our transatlantic neighbors, 
ahead of us in many things, are most decidedly in advance of the 
old country in providing for the care of their sick sailors." 

In the year 1875, j"st four years after the reorganization of the 
Service, Congress enacted (act approved' March 3, 1875) ^^^ here- 
after the salary of the Supervising Surgeon General of the United 
States Marine Hospital Service shall be paid out of the Marine 
Hospital Fund, at the rate of four thousand dollars a year, and the 
Supervising Surgeon- General shall be appointed by the President, 
by and with the advice and consent of the Senate. In another act 
approved the same day, provision was made for the care of seamen 
of foreign vessels at such rates and under such regulations as the 
Secretary of the Treasury may prescribe. 
i This act also provided for the increase of compensation before 

!' mentioned for the Supervising Surgeon- General. It was during this 

fiscal year, too, that the department issued the first circular letter to 
United States ofiicers defining their duties with reference to quaran- 
tine and public health. The medical ofiicers of the marine hospital 
service were especially directed to inform themselves fully as to the 
local health laws, and regulations based thereon, and in force at their 
respective ports and stations ; and strict compliance with such laws, 
and prompt assistance in the enforcement of the same, when requested 
by competent authority, were enjoined. The quarantine law under 
j ■; which these instructions were issued was passed as far back as 1799 

(R. S. 4792). It was during the year 1875 also that the first marine 
hospital of the pavilion style of architecture was opened. This hos- 
pital is located in San Francisco and is now in active operation. 
; Similar hospitals have since been built and are in use at New Orleans, 

I I La., Memphis, Tenn., Cincinnati, Ohio, St. Louis, Mo., Cairo, 111., 

Baltimore, Md., and Evansville, Ind. 



1! 



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THE UNITED STATES MARINE HOSPITAL SERVICE. 3O9 

Hospitals of the older or block style are still in use at Boston, 
Mass., Portland, Me., Louisville, Ky., Wilmington, N. C, Mobile, 
Ala., Cleveland, Ohio, and Detroit, Mich. The present hospital at 
New York (leased from the Marine Society) is also an old-style 
building. Some of the old block hospitals have bad histories, but 
they are now, thanks to improved plumbing and better administration, 
in good sanitary condition, and the results of treatment, medical 
and surgical, compare very favorably with the best results in the 
pavilion hospitals. 

The sanitary condition of the old hospital at Detroit, for example, 
was so bad only a few years ago that the medical officer then in 
charge recommended that permission be granted to admit and treat 
all surgical cases in one of the local hospitals or in rented rooms, so 
as to avoid the invariable complication of erysipelas. Suffice it to 
say that for the last four years not a single case of contagious or infec- 
tious disease or wound infection of any kind originated in this hos- 
pital, while more surgical operations have been done than ever 
before. And this is practically the report of improvement at all the 
older hospitals where modern methods prevail and " the next thing 
to godliness " is the rule. 

It is not the purpose of this paper to discuss the general question 
of hospital construction, nor by any means to discourage the erection 
of pavilion marine hospitals. The pavilion plan is probably the best, 
all things considered, that has yet been devised. But if the older 
style hospitals were as bad to-day as they were reported to be when 
the pavilion was introduced, they should be destroyed forthwith. 
As a matter of fact they are not so bad, and, as before intimated, 
results considered, they must now be pronounced good. 

Differences of opinion as regards the relative merits of different 
style hospitals are to be expected. Surgeon John Vansant, who has 
had extensive experience in hospital work, expressed his views a 
number of years ago as follows :* 

" I have to say that I was once a strong advocate of the pavilion 
plan for all hospitals, but I have now modified my views, though I 
have not positively decided what other plan I would substitute for 
the pavilion. In time of war the pavilion plan is undoubtedly the 
best, for then there are as many nurses and other attendants, as well 
as officers, money and supplies of all sorts, as can be wished for; but 
in times of peace, and for a civil hospital, I think the pavilion plan 

•Annual Report M. H. S. 1883. 



3IO STONER. 

I 

I 

I is more expensive and more difficult to administer. It would also be 

, less comfortable in a cold climate or in winter, and on the score of 

I healthfulness or ventilation, etc. I doubt if it has any advantages 

; over a two- or three-story hospital. I think as a general thing the 

wards of our hospitals are too large; I prefer a greater number of 

smaller rooms." 

A few days ago I addressed a letter to Surgeon Henry W. Saw- 

( telle, of the United States marine hospital service, requesting his 

opinion on the merits of pavilion hospitals as compared with the 
block style of marine hospitals. The following is a copy of his 
remarks sent to me by return mail : 

''As hospitals are for the care and treatment of the sick and 

wounded, the merits of the various hospitals should be decided upon 

the results of treatment as shown by their records, assuming, of 

course, that the administration and care of the hospitals have been 

careful and efficient. Unfortunately I have no such data at hand, and 

I shall therefore content myself by giving my views based upon 

experience at the different hospitals, without reference to statistics. I 

'; have served at one pavilion hospital, the one at San Francisco, and 

'•'■ at several of the older or block style, namely, St. Louis, New York, 

I Detroit, Portland, Me., and Boston. Ventilation for these hospitals 

is obtained mainly through the windows and doors, and the app>oint- 
; j ments generally are below the standard of requirements of hospital 

;' I buildings according to modern ideas. From these remarks it will be 

seen that both styles are open for improvement. In regard to the 
old hospitals of the Service, their bad histories are matters of record 
— outbreaks of erysipelas, gangrene and pyaemia were frequent prior 
to the reorganization of the Service in 1871, and for some time there- 
after. Such a record was undoubtedly due very largely to the fact 
that for many years the marine hospital service had been under the 
control of politicians, and political doctors, who happened to be 
friends of the collectors of customs, or political allies of sufficient 
importance to attract the attention of the appointing power, were the 
medical heads of the hospitals, who paid but little attention, compara- 
tively, to their duties, while the collectors of customs were the cus- 
todians of the hospital buildings, and all matters pertaining to the 
service passed through their hands for approval or disapproval. It 
is not wonderful then, considering such a history, that at the date of 
reorganization in 1871 the marine hospitals throughout the country 
which were of the block plan were found to be in such an infected 



I ■ 



I 

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1 



t : 



: i 

1 
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1 



THE UNITED STATES MARINE HOSPITAL SERVICE. 3 II 

condition that the result of treatment was unsatisfactory and the per- 
centage of deaths large. Cleaning up old hospitals means prevention 
of disease in the same sense that proper environment and personal 
cleanliness mean prevention of cholera. Hence it will be under- 
stood that after a generd cleaning and repairing of the old hospitals, 
it was observed by the medical officers that the success attending 
their treatment of patients increased correspondingly. After about 
twenty years service in these hospitals, including three and one-half 
years at the San Francisco hospital, which, as before stated, is of the 
pavilion plan, my experience in relation to the success of treatment 
of patients in the old-style hospitals as compared with the pavilion 
hospital is about the same. For example, at the Boston hospital, 
which was built in 1859 and which has a bad history, not a case of 
erysipelas has developed in the wards during the past two years, and 
no complications have succeeded surgical operations. Primary union 
after operations is a common occurrence, and I may say that the 
same is true at other hospitals of similar design where I have served. 
No greater success was observed at the pavilion hospital. In con- 
clusion I may say that for economical reasons and convenience of 
management I am in favor of pavilion hospitals for the Service, 
though I am free to admit that, in case expense is no object, hospitals 
constructed on the block plan and provided with proper ventilation 
and all modern appointments, would meet all the requirements for 
the successful treatment of the sick and injured in as large a measure 
as upon any other plan." 

Supervising Surgeon-General John M: Woodworth, who had been 
chief officer of the Service from its reorganization, died in the month 
of March, 1878, and Surgeon John B. Hamilton, who had been ordered 
to Washington for temporary duty in charge of the bureau during 
the illness of the chief officer, was soon thereafter appointed by 
President Hayes to the office made vacant by the death of Dr. 
Woodworth. 

In 1879 the regulations governing the Service were revised. 
Several of the provisions contained in the original regulations of 
Oct. I, 1873, had since the latter date been repealed or modified by 
circular, etc., and new paragraphs were added in conformity with 
the law passed in 1875. 

During the year 1878 a law was passed establishing a national 
quarantine, and the Supervising Surgeon-General of the marine 
hospital service, under the Secretary of the Treasury, was empow- 



312 STONER. 

ered to frame regulations governing quarantine, but no appro- 
priation was made to carry the act into effect. During the same 
year the terrible epidemic of yellow fever occurred in the Mis- 
sissipi Valley, and in February following, Congress passed another 
law (act approved Feb. 3, 1879) establishing a National Board of 
Health. The latter act embodied all the essential provisions of the 
former,, but changed the executive authority by substituting a board 
(national board) composed of seven members, and carried with it 
a large appropriation. The act of 1879 was limited to a period of 
four years, and upon its expiration the law of 1878 was revived, and 
became operative by means of the contingent fund appropriated by 
Congress to be expended by the President of the United States, in 
his discretion, in preventing the spread of epidemic disease and in 
maintaining quarantines at points of danger. This discretion was 
used by the President as above indicated, and the work contemplated 
by the appropriation act was performed through the agency of the 
marine hospital service, in aid of State and local boards of health, 
and in accordance with the act of April 29, 1878. 

It is hardly necessary to add that the precedent thus established 
has been followed up to this time, or until the passage of the recent 
act (approved February 15, 1893) granting additional quarantine 
powers, and imposing additional duties upon the marine hospital 
service. 

In thus briefly reviewing the history of the national quarantine serv- 
ice, and the provisions contained in the several acts, the remarks of the 
late Supervising Surgeon-General Woodworth must not be forgotten. 
After reading a paper before the International Medical Congress in 
Philadelphia in 1876 (two years before the enactment of the law of 
1878), he said : ** From what has preceded, the following conclusions 
seem to be justified : i. The supervision of ocean travel ought to be 
directed to securing good sanitary conditions for vessels at all times, 
out of as well as in port. 2. A system of port sanitation should be 
adopted and administered for each country or place separately, and 
should be modified in particular cases by taking into account the 
liability of the port to infection, the period of incubation of the disease, 
the length of time consumed in the voyage, and the measures enforced 
by the vessel eii route, 3. In some countries the detention of pas- 
sengers and crews of ships hailing from infected ports is warranted, but 
for such time only as is necessary to complete the period of incubation 
of cholera or of yellow fever, counting from the date of departure from 



THE UNITED STATES MARINE HOSPITAL SERVICE. 3I3 

an infected port or of landing from an infected vessel ; in no instance 
should passengers or sailors be held for observation on board an 
infected vessel, and such vessel should not be detained beyond the 
period required for inspection and for thorough disinfection and 
cleansing. 4. Recognizing the fact that the morbific causes of infec- 
tious diseases may sometimes elude the most vigilant sanitary super- 
vision of shipping, the importance of wisely directed internal sanitary 
measures can scarcely be overestimated. 5. As far as America is 
concerned, it is desirable that prompt and authoritative information 
should be had of the shipment of passengers or goods from districts 
infected with cholera or yellow fever, thereby insuring the thorough 
disinfection of infected articles. 6. The endemic homes of cholera 
and yellow fever are the fields which give the greatest promise of 
satisfactory results to well directed and energetic sanitary measures, 
and to this end an international sentiment should be awakened, so 
strong as to compel the careless and offending people to employ 
rational means of prevention." 

These views of Dr. Woodworth were recognized in the act of 
1878. In fact the said act is sometimes called the Woodworth law. 
But as before indicated, the law of 1879 changed the executive auth- 
ority from the Supervising Surgeon-General to the National Board. 
Under these laws national quarantine stations were established at 
several points on the Atlantic coast, and inspection stations at various 
times, when necessary, were maintained at points of danger on the 
frontier. Sanitary inspectors were also stationed at Havana and 
Vera Cruz to give prompt notification relative to the sailing of vessels 
bound for the United States, so as to aid in the prevention of the 
introduction of yellow fever. 

At London and Liverpool inspectors were appointed to give timely 
information of the shipmenfof Egyptian rags or any other articles 
sent through those ports from infected localities. Inspectors were 
also appointed at the principal European ports to inspect vessels and 
emigrants bound for the United States. 

In 1885 the regulations of the marine hospital service were again 
revised. A section for the government of national quarantine was 
added, and the whole was approved by the Secretary of the Treasury 
and by the President of the United States. In January, 1886, Super- 
vising Surgeon-General Hamilton resumed the publication of the 
Weekly Abstract of Sanitary Reports, as required by the act of 1878. 
During the same year or the year preceding, he recommended that 



'I 



1 

i 



314 STONER. 



the national quarantine stations ** be made permanent, and that they be 
equipped with all the necessary appliances known to modern sanitary 
science for the treatment of infected vessels and their cargoes, so that 
not only may immunity from the importation of contagious diseases 
be secured at those stations, but such security be had with the least 
possible obstruction to commerce." In 1887 he recommended the 
establishment of a station on the Pacific coast. In 1888 a law was 
passed (approved August i) making the national quarantines on the 
I Atlantic and Gulf coasts permanent institutions, and providing for 

the establishment of three stations on the Pacific coast.* An appro- 
priation of five hundred thousand dollars was made to carry out the 

■ }| purpose of this act. In 1890 an act was passed to prevent the intro- 

duction of contagious diseases from one State to another and for the 
punishment of certain offenses. 

In June, 1891, Supervising Surgeon-General John B. Hamilton, 
under whose administration of the marine hospital service all the 
national quarantine work up to date had been performed (except dur- 
ing the active period of the national board of health) resigned his 
commission as Supervising Surgeon-General, and Surgeon Walter 
Wyman, then on duty in the bureau as chief of purveying and 
quarantine division, was appointed by President Harrison to 
be Supervising Surgeon-General in place of John B. Hamilton, 

yj resigned. Dr. Hamilton was at the same time and by his own 

'^ request reappointed by the President to be a surgeon in the marine 

hospital service, and assigned to duty at Chicago, 111. 

The latest and most comprehensive legislation affecting the marine 
hospital service, and of course through it the national quarantine 
service and the country at large, is contained in the act (approved 
February 15, 1893) granting additional quarantine powers and 
imposing additional duties upon the marine hospital service. 
Under the provisions of sections 2, 3 and 4 of this act, medical 
officers of the marine hospital service have been detailed to serve, 
and are now on duty, in association with the consuls at various 
foreign ports, and from them all necessary information is received 
relative to the sanitary condition of vessels, cargo, crew and passen- 
gers about to depart for the United States. By this means the 



* National Maritime Quarantines are located at North Chandeleur Island, 
La.; Tortugas Islands, Fla.; Blackbeard*s Island, Ga.; Cape Charles, Va.; 
Delaware Breakwater, Del.; Reedy Island, Delaware River ; Port Townsend, 
Washington ; San FVancisco and San Diego, California. 



THE UNITED STATES MARINE HOSPITAL SERVICE. 315 

ordinary consular bill of health is made to be a certificate of actual 
observation by a responsible officer whose sole duty is to aid in the 
prevention of the introduction of contagious disease into the United 
States. 

New quarantine regulations have been framed by a board of 
surgeons under the direction of Supervising Surgeon-General 
Wy man, who convened* the board for the purpose, and the said 
regulations have been promulgated by the Secretary of the Treasury. 
A very large appropriation is now available, and the Supervising Sur- 
geon-General, under the direction of the Secretary of the Treasury, 
is making extensive improvements at all stations and in various ways 
increasing the efficiency of the Service. At New York, Boston and 
New Orleans the maritime quarantines are owned and operated by 
the state or municipality, but the law requires the Supervising Sur- 
geon-General, under the direction of the Secretary of the Treasury, 
to co-operate with and aid state and municipal boards of health in 
the execution and enforcement of the rules and regulations of 
such boards, and in the execution and enforcement of the rules 
and regulations made by the Secretary of the Treasury to pre- 
vent the introduction of contagious or infectious disease into the 
United States ; . . . . and also requires that all rules and regulations 
made by the Secretary shall operate uniformly and in no manner 
discriminate against any port or place; .... and at such ports and 
places within the United States where quarantine regulations exist 
under the authority of the state or municipality which in the opinion 
of the Secretary of the Treasury are not sufficient to prevent the 
introduction of such diseases into the United States, the Secretary 
shall, if in his judgment it is necessary and proper, make such addi- 
tional rules and regulations as are necessary, .... but if the State 
or municipal authorities shall fail or refuse to enforce said rules and 
regulations, the President shall execute and enforce the same, .... 
and may detail or appoint officers for that purpose." 

It is to be hoped that the relations between the national and the 
State quarantine will always remain within the bounds of co-operation 
and aid, and that both may strive how best to work and agree, until 
such time as the combined efforts may result in better understanding, 
and above all, in the accomplishment of the objects sought to be 
accomplished by modern quarantine. An observance of the mini- 
mum requirements of the regulations will be a sufficient guard 
against any conflict of authority. 



3l6 STONER. 






Medical officers of the marine hospital service are also under the 
laws of March 3, 1891 and March 3, 1893, required to serve as medi- 
cal inspectors in the immigration service. The proper performance 
of this duty must also of necessity result in valuable aid to public 
health. 

From the foregoing compilations and remarks it will be observed 
that the marine hospital service covers a large field. The Service 
proper is a peculiarly American institution. It was originally estab- 
lished and is at present maintained for the benefit of the sailors of the 
mercantile marine. From its beginning in 1798 until 1884 every sea- 
man employed on a vessel of the United States contributed to its sup- 
port by thVpayment of a small tax, at first at the rate of twenty cents a 
month, and later forty cents a month while actually employed. In 1884 
by an act of Congress the hospital tax was abolished, and in its stead 
the tonnage tax received from foreign vessels was made available for 
the ordinary expense of the Service (for the care and treatment of 
sick and disabled American seamen). In addition to the treatment 
in hospital a system of outdoor or dispensary relief was inaugurated 
when the Service was reorganized, and this has gradually increased 
year after year until there are now about forty thousand cases fur- 
nished outdoor relief annually, while the hospital cases number about 
sixteen thousand. During the year 1892 there were 37,588 of the 
former and 16,022 of the latter. 

The physical examination of candidates for appointment in the 

revenue cutter service, and of officers for promotion in that service, 

is made by medical officers of the marine hospital service. Appli- 

'I cants for employment as keeper or surfman in the United States life 

saving service are also examined as to their physical condition and, 
if appointed, instructed in methods for the resuscitation of the 
apparently drowned. Pilots must also pass an examination before a 
medical officer of the marine hospital service as to their ability to 
distinguish the colored lights used at sea. 

The regular corps of the United States Marine Hospital Service 
consists of the Supervising Surgeon-General, surgeons, passed assist- 
ant surgeons, acting assistant surgeons, hospital stewards and hos- 
pital attendants. The Supervising Surgeon was made a commissioned 
officer in 1875 and the title of his office was changed to Supervising 
Surgeon- General. In 1889 statutory provision was made for the 
appointment of all subordinate medical officers, the requirements 
being essentially the same as had previously governed by regulation 



THE UNITED STATES MARINE HOSPITAL SERVICE. 317 

and under which an average of about eighty percent of the applicants 
had been rejected. The following is the text : 

" Medical officers of the Marine Hospital Service of the United 
States shall hereafter be appointed by the President by and with the 
advice and consent of the Senate; and no person shall be so appointed 
until after passing a satisfactory examination in the several branches 
of medicine* surgery and hygiene, before a board of medical officers 
of the said Service. Said examination shall be conducted according 
to rules prepared by the Supervising Surgeon-General and approved 
by the Secretary of the Treasury and the President. Section 2. — 
That original appointments in the service shall be made to the rank 
of assistant surgeon ; and no officer shall be promoted to the rank of 
passed assistant surgeon until after four years service and a second 
examination as aforesaid, and no passed assistant surgeon shall be 
promoted to be surgeon until after due examination : provided that 
nothing in this act shall be so construed as to affect the rank or pro- 
motion of any officer originally appointed before the adoption of the 
regulations of 1879 ; and the President is authorized to nominate for 
confirmation the officers in the Service on the date of the passage of 
this act." 

Medical officers are subject to change of station as the exigencies 
of the Service may require, and are not allowed to remain at any one 
station for a longer period than four years, unless specially authorized 
by the Department. 

Acting assistant surgeons are appointed by the Secretary of the 
Treasury upon the recommendation of the Supervising Surgeon- 
General. They are are not usually subject to change of station. 
Hospital stewards are appointed to the general service by the Secre- 
tary of the Treasury, after passing a satisfactory examination before a 
medical officer of the Service. Hospital attendants are employed by 
the medical officer in charge of a station subject to approval of the 
Department. The different details for attendants are engineer, fire- 
man, cooks, nurses, watchmen, night nurse, ambulance driver, 
gardener, launderer or laundress, and general service men in dining- 
room and about buildings and grounds, and dispensary attendant. 
The marine hospital office or dispensary is usually located in or near 
the custom-house. Medical officers are required to visit patients in 
hospital at least once a day, and oftener if necessary, to make a gen- 
eral inspection at least once a week, and to supervise all matters per- 
taining to the service of the station of which they are in command. 



i 



f 



318 STONER. 

At the larger stations two or more medical officers are usually on 
duty ; at the smaller hospital stations only one. And at stations where 
there are no hospitals belonging to the government, but where the 
service is large enough to warrant it, one medical officer is assigned 
to duty and placed in charge of all Service matters at the port. At 
the still smaller stations acting assistant surgeons are appointed ; they 
are also sometimes designated sanitary inspectors, if required for 
duty of that kind, and occasionally when additional medical services 
are needed and eligible candidates are not available for appointment 
as assistant surgeons, acting assistants are appointed temporarily to 
assist the medical officer at a station. Internes are appointed by the 
medical officer subject to approval of the Department. The latest 
regulations governing the marine hospital service proper were 
issued in 1889. New regulations for the government of national 
quarantine stations have been issued since the passage of the law and 
are now in active operation. 

The Supervising Surgeon-Generars office is a bureau of the Treas- 
ury Department. It is located in Washington, D. C, at present in 
the Butler Building on Capitol Hill. The officers and employees 
now on duty in the bureau are the Supervising Surgeon-General, two 
surgeons (one detailed as chief of the purveying division, and one 
chief of the quarantine division), two passed-assistant surgeons 
(one in charge of the bacteriological laboratory, and one as execu- 
tive officer or acting chief clerk), one assistant surgeon, assigned 
to duty on the Weekly Abstract of Sanitary Reports, one chemist, 
and the necessary clerks, messengers and laborers. The medical 
officers in the bureau are detailed from the corps by the Supervising 
Surgeon-General, and are subject to orders the same as if on duty 
at any other station. 

The writer served as chief of the purveying and quarantine divi- 
sion from January 1885 to November 26, 1888. 

Discussion. 

The Chairman. — We are very much obliged to Dr.Stoner lor his 
paper. I am somewhat familiar with the history of the Marine Hospital 
Service in recent days, because I once had occasion, as Dr. Stoner 
states, to look into the subject, having reported for special duty to the 
Secretary of the Treasury in 1869 or 1870, and inspected almost every 
marine hospital in the United States. I recommended the appoint- 
ment of a special supervising medical officer and the giving him full 



HOSPITAL CONSTRUCTION. 3I9 

power. The condition of affairs at that time was very bad ; there 
was dishonesty in a number of the hospitals, and there were only one 
or two that were in good condition. The result was that a new 
law was passed and a medical officer, Dr. Woodworth, appointed, 
a very excellent appointment. The regulations that have been made 
(Dr. Woodworth on his death being succeeded by Dr. Hamilton, 
and he on his resignation by Dr. Wyman) have, I believe, resulted 
in bringing the Service into a very excellent condition; the hospitals 
that they manage themselves being in good order, and a very careful 
scrutiny of the hospitals in which the patients are treated by contract 
being maintained. As Dr. Stoner remarks, it is purely an American 
institution ; there is nothing like it precisely in any European country, 
and our foreign friends find it hard to understand, because they are 
always getting it mixed up with the naval service. I am very glad 
that we shall have this paper published in the proceedings of this 
congress, as it will give many persons a more definite notion of the 
scope and purpose of this Service than they at present have. 



HOSPITAL CONSTRUCTION ILLUSTRATED BY 

STEREOPTICON VIEWS. 

By L. S. Pilcher, M. D., 

Brooklyn^ N. V. 

Dr. Pilcher. — '* I would like to say at the outset that the object 
of the present demonstration has been in connection with essays and 
discussions upon ideal hospitals, to present views of existing institu- 
tions, with their defects and limitations, with their advantages and 
lessons. 

Slides for this purpose have been solicited by the committee from 
various sources, but the failure of many hospital superintendents to 
co-operate limits the views which we shall present this afternoon to 
the Johns Hopkins Hospital, Baltimore, the Boston City Hospital, 
and to the institutions of New York and Brooklyn. 
. Thanks are due to Dr. Hurd, to Dr. Rowe, and Mr. A. R. Pard- 
ington, and especially to Dr. H. P. DeForest, of Brooklyn, to whose 
skill and interest are due a great many of the slides that are to be 
exhibited. 



320 FIELD. 

It is safe to say that an appreciation of the requirements of ade- 
quate hygiene in the construction of a hospital i$ a thing of the last 
half of the present century. I propose to first present a series of 
institutions illustrative in some measure of the progressive develop- 
ment of hygienic hospital construction." 

The speaker then presented several views of Bellevue Hospital, 
New York, the eastern fa9ade, the floor plan of the hospital, exterior 
and interior views of the Sturges ward, Townsend ward, various 
pavilions and tents, and the morgue ; showing the gradual growth of 
the hospital since it was first constructed, and illustrating the many 
defects in its construction. Kings County Hospital was then illus- 
trated, the interior and exterior, also views of the various wards and 
pavilions. The Brooklyn Hospital was next shown, illustrating the 
old style of ward, with windows on one side only. The other hos- 
pitals of New York and Brooklyn illustrated were Long Island Col- 
lege Hospital, St. Vincent*s Hospital, St Peter's Hospital, St. Luke's 
Hospital, The Norwegian Deaconesses' Hospital, Mt. Sinai Hospital, 
the New York Hospital, New York Cancer Hospital, Roosevelt 
Hospital (this hospital being very fully illustrated and being referred 
to by the speaker as the first hospital in New York City answering 
the full requirements for isolated pavilion wards), and the Presby- 
terian Hospital, the most recently planned and built hospital in New 
York City. 

The speaker also presented several views of the Johns Hopkins 
Hospital, Baltimore, a series of views of the Methodist Episcopal 
Hospital, Brooklyn, and of the Boston City Hospital. 



DETENTION HOSPITALS FOR THE INSANE. 
By Matthew D. Field, M. D., New York, 

Exatfiiuer in Lunacy, 

It was my privilege, in the summer of 1892, to read a paper before 
the American Social Science Association, on the '* Examination and 
Commitment of the PuMic Insane in New York City." The discus- 
sion and comment called forth by this paper showed the almost 
total absence in this country of reception hospitals for the insane 
while under observation and examination to determine their mental 



DETENTION HOSPITALS FOR THE INSANE. 321 

condition and the propriety of commitment to some institution for 
treatment. It was related by members from various sections of the 
union how the unfortunate individuals of both sexes, who were 
apprehended by the authorities as insane, were sent to prisons and 
county jails, there, to remain in contact with vagrants, tramps and 
criminals, to await the appointment of physicians to make examina- 
tions regarding their sanity. During this detention they received 
little or no medical treatment for the relief of their condition, but on 
the contrary, their surroundings and companions were about the 
worst possible for persons in their state, omitting to say anything 
of the moral effect on very many, and the great wrong perpetrated 
upon sick persons, by associating them with criminals and allowing 
them only the same quarters, food and care that the liberality of 
county officials bestows on tramps and vagabonds. 

The evolution of the reception pavilion for the insane at Bellevue 
Hospital, and the present system of care and the examination and 
commitment of the public insane, are of some interest; they grew 
out of the lunacy legislation of 1874.* 

• Acts of 1874, Chapter 446. 

Section i. No person shall be committed to or confined as a patient in any 
asylum, public or private, or in any institution, home or retreat for the care 
and treatment of the insane, except upon the certificate of two physicians, 
under oath, setting forth the insanity of such person. But no person shall be 
held in confinement in any such asylum for more than five days, unless within 
that time such certificate be approved by a judge or justice of a court of record 
of the county or district in which the alleged lunatic resides; and said judge 
or justice may institute inquiry and take proofs as to any alleged lunacy before 
approving or disappoving of such certificate, and said judge or justice may, in 
his discretion, call a jury in each case to determine the question of lunacy. 

Section 2. It shall not be lawful for any physician to certify to the insanity 
of any person for the purpose of securing his commitment to an asylum, unless 
said physician be of reputable character, a graduate of some incorporated med- 
ical college, a permanent resident of the State, and shall have been in the actual 
practice of his profession for at least three years. And such qualifications 
shall be certified to by a judge of any court of record. No certificate of insanity 
shall be made except after a personal examination of the party alleged to be 
insane, and according to forms prescribed by the State Commissioner in 
Lunacy (with the State Commission in Lunacy) ; and every such certificate 
shall bear date of not more than ten days prior to such commitment. 

Section 3. It shall not be lawful for any physician to certify to the insanity 
of any person for the purpose of committing him to an asylum of which the said 
physician is either the superintendent, proprietor, an officer, or a regular 
professional attendant therein. 



333 FIELD. 

The Commissioners of Public Charities and Correction of New 
York City, under this law, appointed special examiners in lunacy, 
whose duly il should be to examine all cases that should come under 
tjie care of ihe departmeni, and in proper cases to make certificates 
of lunacy and present the same for approval before a judge of a court 
of record, as required by ihe law ; after which the adjudged lunatic 
was sent with such certificate to the insane asylum of rhe depart- 
ment. Such method has continued till the present day. except that 
formerly the chief examiner held the position of city physician, and 
had charge, likewise, of the city prison. Such was the condition of 
affairs when I was appointed examiner in lunacy for the Depart- 
ment of Public Charities and Correction in November. iSSa, my 
senior being Dr. William I. Hardy, the prison physician. Within 
the year Dr. Hardy was relieved of all duties in the department save 
those of examiner in lunacy, and our joint functions became and 
have continued independent. Upon the death of Dr. Hardy in April, 
1886, my present associate. Dr. Allen Fitch, was appointed. 

In the earlier days there was no special place for the reception of 
the alleged lunatic, and he was examined where he might be, in 
prison or hospital. Then all the suspected insane were sent to 
Bellevue Hospital and placed in the "cells." These were two wards 
in the basement of the building, one for males and the other for 
females. In these wards were received not only the supposed luna- 
tics, but all alcoholic, violently delirious and refractory patients of 
the hospital ; and frequently criminal patients were sent there, too, 
for safe-keeping. I remember well visiting the " cells '' as an interne 
^f the hospital when all these classes were received. I was called as 
a surgeon 10 see a wretched woman, who had received a fracture of 
the arm in a drunken brawl, and who had been committed there as 
an alcoholic. It was at night, and the light was dim, and a little 
child, scarcely more than three years of age, was clinging to the 
skirts of her mother, who was sodden with liquor. As I examined 
the arm of the drunken mother, the beautiful, innocent, pleading face 
looked up to me for mercy for her mother ; and 1 could not but be 
gentle with her for the child's sake. I thought if the mother would 
only look upon the child with but a tenth part of that humanity and 
sympathy with which the child looked up to me, what a different 
aspect the case would assume. While this was taking place 1 could 
hear ihe shrieks of fear on all sides from those in delirii 
by which the disturbed lunatic was continually excited. 




lace 1 couia _ 

1 of alcohol, H 



DETENTION HOSPITALS FOR THE INSANE. 323 

The Commissioners of Public Charities and Correction had recog- 
nized the necessity of separating the insane from the alcoholic ; and 
their persistent application had obtained an appropriation for the 
erection of a separate pavilion for the reception of the supposed 
insane. The year 1879 saw the completion of the present reception 
pavilion for the insane at Bellevue Hospital. It was erected in the 
grounds of the hospital, and is a one-story brick building, divided 
by iron doors into two wards, one for males and one for females. 
Each side has a corridor, lighted and ventilated from above, contain- 
ing eight rooms for patients, besides an examination room (which 
contains record and history books, and a medicine and instrument 
chest), a kitchen, where not only food is received for the ward from 
the general kitchen of the hospital, but special diet is prepared as 
the resident physician may direct, the carving is also done, and 
all dangerous knives are kept. One room is set apart as a linen 
closet, where the bedding and necessary clothing are kept for 
patients. There is also a lavatory, bath-room, and closets, removed 
from the ward by a passage ventilated and lighted by windows on either 
side, as well as by windows on either side of the closets. The cells 
were and still are under the care of the house staff, the medical staff 
dividing the service in looking after the cells. When the pavilion was 
first established it was placed under the same care ; the house physi- 
cian, having the supervision of the cells also had the care of the insane 
admitted to the pavilion. The examiners then only passed on the 
mental condition and the propriety of commitment or discharge; the 
treatment of the patient while in the pavilion rested with the house 
physician, who had no special training in the care of the insane, and 
who had already sufficient work to care for his patients in his regular 
service, where his interest and heart really were. The oversight of the 
alcoholic and insane patients was an extra and entirely secondary duty 
of a busy physician. Soon after my appointment in November, 1882, 
Dr. Henry V. Wildman, who had had several years* experience as 
assistant physician at the* asylum on Ward's Island, was appointed 
resident physician at Bellevue Hospital, in charge of the pavilion for 
the insane. He resigned in October, 1887, and was succeeded by 
Dr. Stuart Douglas, who had been assistant physician at the City 
Asylum for over six years, and who is still resident physician. In 
1885 the general oversight of the pavilion was placed under Dr. A. 
E. MacDonald, the General Superintendent of the New York City 
Asylums. 



f 



i 

V 



{ 

r 



324 FIELD. 



We may now ask, Whence come the patients? The majority 
received at the pavilion are committed by the police justices to the 
care of the Commissioners of Public Charities and Correction for 
examination as to sanity. The usual term of commitment is five 
days, ^hy five days nobody seems to know, except that such has 
been the custom, and that length of time is usually sufficient for the 
\ purpose. The police justices commit for examination regarding 

I sanity such persons as manifest evidence of insanity in these 

) classes : 

j I St. Those persons who are arrested for petty offenses, the nature 

j and manner of the occurrence indicating an unbalanced mind. 

I 2d. Those who interrupt public meetings or divine service, who 

t preach or orate in public places, their conduct appearing to be irra- 

) tional. 

3d. Persons making complaint before police justices, at police 
stations, in other courts, to the district attorney, or other public 
officials, of wrongs and persecutions, or presenting claims that 
' appear to be imaginary. 

4th. Where complaint is made by citizens of persons who annoy 
them upon pretense that seems irrational. 
, 5th. Persons who may be found by the police wandering about the 

! streets in an aimless or purposeless manner, or acting in a strange 

manner, or who are unable to give a rational account of themselves. 
6th. Those who have attempted to commit suicide. 
7th. Those who are brought before a public magistrate, where the 
charge or testimony would warrant the suggestion that the individual 
might be insane and irresponsible. 

It is not infrequent for police justices to commit persons for exam- 
ination, and to endorse across such commitment, " To be returned to 
court if found not insane." In fact, police justices endeavor to be 
just, and to commit no person for lesser crimes, when evidence is 
produced to indicate insanity and irresponsibility, until the question 
of sanity has been passed upon by the city examiners. In cases of 
grave crime, they commit for trial, leaving the court of higher juris- 
diction to determine the question of sanity and responsibility. 

The superintendent of the poor, acting for the Commissioners in 
cases that are made public charges, where evidence is furnished that 
such person is insane and requires care and treatment as an insane 
person, gives permits for admission to the pavilion for examination. 
The examining physician for the department, where admission 
is sought to some hospital and his examination leads him to suspect 



DETENTION HOSPITALS FOR THE INSANE. 325 

insanity, gives permits for admission to the pavilion for special 
examination regarding the applicant's sanity and fitness for admis- 
sion to the city asylums or other institutions of the department. 

A certain number of patients are brought by ambulance from 
residences; where the statement of friends or the conduct of the 
patient leads the ambulance surgeon to conclude that the patient is 
insane. Some are sent directly from police stations, without a 
commitment from a police justice. These are usually excited, violent, 
or sick cases, in which the police feel they are not justified in retain- 
ing the individual at the police station for the time required to obtain 
the formal commitment. A few cases are admitted by the resident 
physician, where patients are bropght by friends, with letters from a 
family physician, or come voluntarily, or consent to temporary res- 
traint. Where the patient is violent, dangerous, or very sick, the 
resident physician feels justified in admitting to the pavilion without 
the formality of a commitment by a magistrate. In other cases it is 
his habit to recommend an application to some police justice for 
formal commitment. 

Patients are transferred from the regular wards of Bellevue Hos- 
pital and from the alcoholic ward, but only after the examination and 
approval of the resident physician of the pavilion (he indorsing the 
card with his signature) before the transfer is made. Patients are 
received from other hospitals and institutions when brought to Belle- 
vue by ambulance. (I have thus far gone into this subject of admis- 
sion to show the precautions that are taken to prevent the temporary 
detention even of any improper case in the examining pavilion.) 

Where cases of insanity develop at other hospitals or institutions 
in the care of the department of Charities and Correction, by order 
of the general superintendent it is the duty of the resident physician 
of such institution or hospital to report to the examiners in lunacy, 
in writing, the existence of such patient and a liistory of the 
case, and to state that, in his opinion, the patient is in such physical 
condition as to justify his transfer to the asylum. The examiners 
are directed to visit such patients at the various institutions where 
they may be, and pass judgment on the question of sanity and pro- 
priety of commitment to some of the city asylums. The examiners 
prefer to make their visits separately and to arrive at independent 
conclusions, though they have subsequently to unite in a dual 
certificate. 

Under the present dual certificate required by law, we are in the 
habit of dividing the work ; and, while one examiner makes out the 



I 



1 



326 



FIELD. 



u 



certificates for the males, the other does so for the females. We 
alternate each month. The first examiner, after the completion of 
his examination (if he considers the patient insane), makes out a cer- 
tificate, and makes oath to it before a notary public, leaving the 
certificate in the notary's charge. The second examiner, if of the 
same opinion, signs the certificate prepared by the first examiner, 
with such additions as his examination may lead him to make ; then 
makes oath, as did the first examiner, before the same notary who 
acknowledged the certificate, and in this form it is presented to the 
judge for approval. Should the two examiners disagree in any case, 
as sometimes occurs, the case is referred to the resident physician, 
whose opinion decides the disposition of the case. 

Discretion is exercised by the examiners and by the resident phy- 
sician in regard to the discharge of patients to the care of friends and 
relatives. If the friends show a disposition and ability to care for the 
patients, they are usually discharged to their care, if they sign a con- 
tract agreeing properly to provide for them. If the patient be 
decidedly dangerous to himself and others, we usually insist that 
arrangements be made with some institution for proper care and 
treatment. All that is required is a reasonable assurance, that both 
the patient and the community are properly guarded. When once 
a patient is lodged in some institution, the examiners consider their 
responsibility ended. Of course, improper commitment or discharge 
would be still chargeable to them. Beyond that they could hardly 
be held responsible. The examiners stand between the patient and 
the community. They must guard the welfare of the patient, con- 
sider his right to enjoy liberty and the pursuit of happiness; and at 
the same time they must guard and protect the community. 

The following table will show the number of patients received dur- 
ing the past four years and their disposition : 

Transfer'd Transfer'd Transfer'd 



Sex. 


Admissions. 


to City 
Asylum. 


to other 
Asylums. 


to other 
Institutions. 


Dischar'd. 


Died 


■8«H"-,e. 


997 
854 


650 
616 


87 
36 


135 
104 


109 
87 


8 
II 


•«89{^eti.e. 


843 


641 
625 


139 
46 


87 
63 


198 

93 


16 
12 


•«9o{^,t;,e. 


1,066 
830 


658 
601 


71 

37 


193 

70 


»3S 
103 


12 
14 


•«9.{^et;.e. 


1. 138 
866 


724 
671 


S6 
23 


187 
54 


144 
100 


16 
17 



Total. 



7,669 5,186 



495 



893 



969 



106 



DETENTION HOSPITALS FOR THE INSANE. 327 

Total commitments 74.09 per cent. . 

** *• ^ to city asylums 67.62 ** 

** ** to other asylums 6.47 ** 

^* '* transferred to other institutions. . . 1 1.64 " 

** " discharged 12.63 " 

*• " died 1.38 «* 

The percentage of discharges when I was first made examiner was 
over thirty-three per cent. The percentage has gradually dimin- 
ished, from the great care exercised in the exclusion of admission of 
improper cases to the pavilion. The number of admissions has 
decreased but slighdy, but the number of improper admissions has 
lessened very much. This is due very largely to the oversight of a 
competent resident physician with increased power. 

The reception pavilion is in every respect a hospital, with a resi- 
dent physician and competent and trained attendants. Unnecessary 
detention at police stations and prisons and the mingling of the 
insane with the criminal class, are avoided. All patients transferred 
from the pavilion to the asylum are accompanied by attendants of 
their own sex, who remain with them until thev are turned over to 
the care of the asylum authorities. Opportunity is afforded in very 
many cases to obtain a history of the patient, and to consult with 
friends and allow them the privilege of providing for the patients in 
other institutions, if they have the means and disposition to do so. 

I have brought this subject, with the description of the workings 
of the reception pavilion at Bellevue, to your attention in the hope 
that your interest might be secured in the starting of a movement for 
the establishing of similar institutions in every large city in the United 
States. This plain and inexpensive building, with but sixteen sleep- 
ing rooms, has received at least twenty-five thousand suspects since 
its opening in 1879. It has served its purpose well, though at times 
hasty examinations have been required to prevent overcrowding. 

An ideal institution for this purpose would be an hospital con- 
structed upon the pavilion plan, for the reception of the insane, 
inebriate and neurotic, with a small amphitheater, and sufficient 
wards for proper classification and detention for a reasonable time. 

A competent visiting, examining, and resident staff of medical 
officers should be chosen and clinical instruction regularly given. 

I would insist on full records being kept of all cases admitted, and 
would make the past history of each patient an important matter, to 
be patiently and persistently sought after and carefully recorded. 



328 HIRST. 

Such a hospital would secure prompt, humane and scientific treai- 
meni. The opportunity afforded for longer observation, securing 
histories and examinations, would result in more complete and accu- 
rate certification. 

There being no need for hasiy transfer to other institutions, the 
feeble, sick, and certain selected cases could be detained for treat- 
ment, and clinical instruction would be easily accessible to the entire 
medical profession. 



THE CONSTRUCTION OF MATERNITY HOSPITALS. 
By Barton Cooke Hirst, M, D., of Philadelphia, 

Prf/tssor of ObstflrUs, Umvtrsity of Pennsyhania, 

The writer must disclaim at the outset any special knowledge of 
hospital construction. The only claim he has to write on the subject 
at all is the fact that he has made the plans for and superintended 
the erection of a maternity hospital under conditions and limitations 
that must prevail in many similar undertakings in this country. It 
may, therefore, be helpful to others who are charged with such a 
task in the future, to know how certain problems thatwill beset them 
have been met by us. 

Some five years ago it was determined to erect a maternity hos- 
pital in connection with ihe medical school of the University of 
Pennsylvania, There were no funds at hand for the purpose. All 
that the University authorities could do was to grant the land upon 
which the building was to sland. Everything else— the collection of 
the money for building, and all the details of the building itself— were 
left to the newly elected professor of obstetrics. The questions to be 
faced were the following: 



of i 



1. The plan of a buildi 
of palienis during confinement, a 

2. The best architectural pla 
isolation, ample air space during 




mple capacity for a large number 

I yet of small cost, 

to secure to each patient privacy. 

id after delivery ; to allow the use 



of each patient for clinical instruction for one or two members of the 
graduating class, without undue exposure; but not to give so much 
space lo each individual patient that the size of the building would 
be excessive and its cost too great. 



THE COXSTRUCTIOX OF MATERNITY HOSPITALS. 329 

The manner in which these requirements were met is best told by 
a description of the building we have begun and will soon finish. It 
was decided upon after much thought, and after an inspection of 
many of the best known maternities in this country and in Europe. 
The latter, however, did not help us much, as it was necessary to 
adopt a plan that differs materially from any other the writer 
knows of. 

By a glance at the illustration it may be seen that the building 
consists of a main structure, with a basement, two stories and a man- 
sard roof, the ground dimensions being about 50X40 feet. From 
each side of the rear runs a long narrow pavilion, one-story high, with 
a ridge ventilator. In the interior of this pavilion is a glass-enclosed 
porch, extending the whole length, an inner corridor, and five sep- 
arate bedrooms, each about 10 feet square. The bath-room and 
water-closet are entered from the glass porch, and are walled off 
from the rest of the pavilion. 

The main building (not yet erected) will contain on each main 
floor two wards with a combined capacity of 14 to 16 beds to the floor. 
The mansard roof provides extra space for at least 12 more beds. 
The basement is to be used for dining-room, ward kitchen, storage- 
room and heating apparatus. 

In the main building pregnant women will be received, not longer, 
if possible, than two weeks before their expected confinement. 
When a woman falls in labor she is transferred to a room in one of 
the pavilions, where she is delivered and will remain for about ten 
days. She is then returned to finish the remaining few days of her 
convalescence in a ward of the main building. By this plan the bed- 
rooms of the pavilions may be filled and vacated three times a 
month, giving us a capacity of 30 confinements in that time; or this 
number may be increased by moving patients back to the main 
building on the 5th, 6th or 7th day. 

Thus during pregnancy, and late in puerperal convalescence, when 
it is not necessary that each patient should have more air space than 
any healthy individual requires, we can economize room ; while during 
confinement, and in the puerperium, each patient has an amount of 
space to herself, a degree of isolation and seclusion in her own room, 
that is rarely, if ever, afforded in the most lavishly equipped and 
expensively erected hospital. 

The writer expected from this plan the following advantages, and 
his expectations have been realized : 



THE CONSTRUCTION OF MATERNITY HOSPITALS. 33 1 

1. It is cheap. Each pavilion presenting a handsome appearance, 
built of pressed brick, with brown-stone sills, and handsomely con- 
structed in the interior, costing $5000. The main building will cost 
$15,000. 

2. It gives the best possible hygienic arrangement of the confine- 
ment rooms, separated from one another, each with its own window, 
a separate ventilator and heating flue, and entered only from the 
inner corridor, which opens directly upon the well-lighted and venti- 
lated glass-enclosed porch. I have never anywhere seen a maternity 
hospital so well planned in this respect. 

3. It gives the women a privacy during confinement that is rarely 
enjoyed in a hospital, and enables us to assign an advanced student 
to the room of the parturient, under an instructor, without exposing 
her to other patients or to other practitioners engaged in the same 
work in a common ward. 

4. It gives a large capacity at small cost. Fox $25,000 we have a 
hospital constructed on the very best hygienic principles, of a hand- 
some appearance, and with a capacity of upwards of 360 confinements 
a year. 

This capacity can be gready increased at any time by the addition 
of a story or two to the main building, and by running a third pavilion 
between the ends of the other two. 

The writer would recommend most strongly this system of separate 
rooms for women in confinement, to any one contemplating the erec- 
tion of a maternity hospital. The alternatives to this plan are delivery 
of a number of women in one room, where they remain during con- 
valescence, or a special delivery room in which the child is born, and 
from which the patient is transported afterward to a ward in which 
she will lie until she leaves her bed. The disadvantages of the former 
are obvious. The danger of infection must be increased ; the sight 
of others in pain, possibly undergoing operation, has a demoralizing 
infiuence upon the parturient and puerperal woman ; and if the cases 
are used for instruction of young practitioners, as they always should 
be, there may be quite a number of students present at one time. The 
writer will not soon forget an experience while interne in a German 
hospital ; returning one night from the opera, he found in on^ gebdrsaal 
fiWQ women in active labor, attended by ten students Aside from 
the bad hygiene of such an arrangement, imagine the feelings of any 
one of these unfortunate women, were she other than a phlegmatic, 
not to say stupid German peasant ! The second alternative, while 
better, is still not the best. A special delivery room has the great 



332 VACHEK, 

disadvaotage, that, used for a large number of birlhs in rapid suc- 
cession, it is exceedingly difficult to keep clean. And, moreover, 
the transportation of ihe woman to another ward directly after delivery 
is attended with not a little risk. 

It seems indisputable that, from a hygienic as well as a humanitariaQ.a 
standpoint, the plan of smgle rooms for parturient patients is the.g 
best. This admitted, the best and least costly plan of a buildin 
will be found to be a combination of a main storage-house fo^ 
patients and attached pavilions with single rooms. 



COTTAGE HOSPITALS. 
By Francis Vacher, 

Mtdkal Offictr of Health for tht CnHnly 9/ Chciltr, Englatti,' 
The First Collage Hospilal. 

To Mr. Albert Napper, surgeon, the honor is due of establishing 
the first "Village Hospital," as he called it. About the year 1855, 
the desirability of making some provision locally for the treatment 
of severe medical and surgical cases was forced on his attention, and 
he made inquiries and interested friends in the subject. Eventually 
a cottage at Cranleigh wa» given by the Rector, rent free, and fitted 
so as to adapt it for use as a hospital at a little over j^so. This hos- 
pital was opened in 1859, six beds being provided for patients. The 
general management was placed in the hands of a committee, but an 
acting manager was appointed, who with the medical ofBcer should 
be responsible for details and report to the committee. An efficient 
nurse was placed in charge of the nursing, and subsequently this 
branch of the hospilal work was supervised by a ladies' committee. 
It was part of Mr. Napper's plan that when the nurse or assistant 
nurse had spare time she might visit the sick at their own homes as 
nurse or dresser. The idea has not been put in practice at Cranleigh, 
but it has elsewhere, and is found to work well. 

Mr. Napper remained associated with his hospital till 1880, when! 
he retired, and his work there has since been carried on by his soo. 
The Cranleigh Hospital is yet in excellent working order, treath 
about 30 patients annually, many of them very severe cases. It 
shows what can be accomplished with the help of skill, care, and peiv 



1 

I 



COTTAGE HOSPITALS. 333 

sonal attention to detail, for the initial expenditure was most trifling, 
and the annual income from subscriptions and donations often does 
not exceed ;^i20. The patients or their friends pay from 3^. 6d. to 
5^. per week for maintenance. 

Other Early Cottage Hospitals. 

The second cottage hospital was opened in i860 at Fowey, a small 
town in Cornwall, having a present population of about 2000. A 
cottage was erected at a cost of ;^450 (the only annual charge in 
respect of it being 105. ground-rent) and partly furnished, eight beds 
being provided for patients ; but the nurse was required to furnish 
her own apartments, and was only to be paid " when her services 
were required to attend any sick person or persons in the hospital." 
When not required, the nurse was allowed to "attend poor women 
at their own homes during their confinement." An arrangement 
such as this is so peculiar, one is not surprised to hear that no yearly 
report is issued, or that some of the patients " are daily supplied wfth 
dinner and perhaps with breakfast " by the persons who got them 
admitted. There is certainly much need of a hospital at Fowey, as 
it is 25 miles from Truro, where the nearest general hospital is situ- 
ated; but it should be differently organized, so as to bring it into 
accord with modern views. The Fowey Hospital is still open and 
receives upwards of 20 patients annually. 

Only two cottage hospitals, so far as I have been able to ascertain, 
were established in 1861 ; the first at Bourton-on-the- Water (Glou- 
cestershire) and the second at Woodbridge (Suffolk). The Bourton 
hospital owes its existence mainly to the exertions of Mr. John Moore, 
surgeon. An old three-story building was obtained, added to and 
adapted, and an army pensioner and his wife were put in charge, the 
latter acting as nurse. It was situated in the outskirts of the village 
and had a good garden. This building was in use till the middle of 
the year 1879, when through the efforts of the committee of man- 
agement an entirely new compact hospital was completed and placed 
at the service of the district. The new building was erected of brick 
and tiles at a cost of ;^ 1,100, on a suitable site given by a resident. 
It was designed to accommodate 10 patients, but only 8 beds are 
provided. The men's ward and women's ward are on the first floor, 
and there is a ward for convalescents on the ground floor, all being 
well proportioned, light and airy, but the sanitary arrangements were 
soon found to be unsatisfactory and had to be put in order. The 
furnishing of the building cost ;^i8o. 



334 VACHEK. 

The Sekforde Hospital at Woodbridge resembles the Bourtoo 
Hospital in having an out-patienls' department, but only 6 beds are 
provided. The annual expenditure at Bourton is a little over ^JOO, 
and at Woodbridge it is a little over ^300. 

In 1862 there was a small hospital and dispensary opened at Pem- 
broke, South Wales. Eight beds were provided and about 40 
patients received annually, but the number of beds was afterwards 
reduced to four. The amount of dispensary work done by this 
institution is trifling and not increasing. 

The fifth cottage hospiial I find any record of was founded in 1863 
at Iver, in Buckinghamshire. A suitable cottage was rented at ^£20 
a year, furnished and provided with 6 or 7 beds and placed in charge 
of a nurse. It was somewhat enlarged in 1S75 and the name changed 
to the Iver, Langley and Denham Cottage Hospital. There are 
now nine beds and the income is increased from about ;^ioo to 
^240 a year. There are no out-patients. 

Jn the same year the first cottage hospital for surgical cases only 
was founded at Walsall in Staffordshire. A house was obtained and 
fitted with 20 beds, and patients were treated free. In a few years 
the number of beds was increased, and in 1880 a new building was 
erected, the money being obtained by public subscriptions. The 
institution is now probably the largest cottage hospital in ihe king- 
dom. It has 42 beds, the average number occupied being 30, and a 
large out-patients' department. The number of in-patienis treated 
last year was 494. and the number of out-patients 4,473. The ordi- 
nary income and expenditure are about ;^i,300. The nursing is done 
by a sister and staff of six nurses. 

A third cottage hospital was opened in 1863. It is situated at 
Redruth, and is called the West Kent Miners Hospital, being origi- 
nally intended for the treatment of convalescents. It was found lo be 
so successful that in 1871 an accident ward was added. The hospital 
now makes up 30 beds, the average number daily occupied being 27. 
Last year there were 198 convalescents and 59 cases of accident 
treated. There is no out-patients' department, neither is there any 
medical staff. Each patient selects his own medical man. The 
special peculiarity of this institution is that it is worked entirely by 
Lord Robartes, the committee paying him 13J. 6i/. per week for each 
accident case, and lis. per week for each convalescent case admitted 
by them. The expenditure last year was ;£ia3i. Lord Robartes 
expends yearly on the hospital more than the amount paid him. 



L 



COTTAGE HOSPITALS. 335 

During 1864 was established a cottage hospital at Ditchingham, 
Norfolk. It secured so much local interest that in the course of a 
few years a subscription for building was commenced, and by July, 
1873, a new hospital was completed at a cost of ;^3000. This is 
called All Hallows Hospital, and appears to be the first cottage hos- 
pital built on the pavilion principle. It provides 20 beds for patients; 
the income is about ;^500 a year. Patients are charged 55. to 10^. for 
maintenance. 

In either 1864 or 1865 a second cottage hospital in Gloucestershire 
was opened — the Tewkesbury Rural Hospital. The erection of this 
building cost only about ;^iooo, yet 20 beds are provided, and there 
is an out-patients' department. The income is derived almost entirely 
from subscriptions; last year it amounted to ;^ 740. 

The next two cottage hospitals opened appear to be those at 
Wallasey, Cheshire, and at St. Andrews in the county of Fife. The 
Cheshire hospital originally provided 10 beds, and now has 18; the 
other originally provided 7 beds, and now has 10. Both were estab- 
lished in 1865. 

The Cheshire hospital has an out-patients' department, and an 
income and expenditure of about ;^38o a year. At St Andrews 
hospital there is no out-patients' department, and the income and 
expenditure are about ;^28o. 

The Cranleigh Hospital and the other eleven cottage hospitals 
already referred to are all at present active working hospitals. In 
1 861 a small cottage hospital was opened at Dinorwic in Carnarvon- 
shire; it contained 8 beds, and was kept open for about seven years, 
when, owing probably to want of funds, it was closed. In 1863, at 
East Grinstead, Sussex, two cottages were given for the purpose of 
establishing a cottage hospital. They were altered at a cost of ;^ 150, 
and furnished by subscription, 7 beds being provided. In 1874, on 
the completion of its eleventh year of work, and after having received 
and treated 300 patients, it was closed, owing to the difficulty the 
founder experienced in raising sufficient funds for current expenses. 
Many years afterwards, i, e,y in 1888, the East Grinstead Hospital 
was resuscitated, 5 beds being provided, and it seems likely to do 
well. Last year the income was ;^434. 

In 1863 also, a cottage hospital providing 8 beds for surgical cases 
was opened at Stockton, Durham, a cottage being rented for the pur- 
pose at £1^, It was successful for many years, but in 1875 ^ larger 
hospital was provided in the same town, and this (which now has 60 
beds) is prospering well. 



336 VACHER. 

The Progress of the Cottage Hospital Movement, 

It has been shown that during the first seven years of cottage hos- 
pitals, 15 were established, 12 of which now survive. Of the three 
which failed after many years of active service, one has been re-estab- 
lished, and one superseded by a larger hospital. The spread of the 
cottage hospital movement after the first seven years was very much 
more rapid. This will be indicated by the list of cottage hospitals 
which I have been at some pains to compile, and now submit {vide 
the Appendix). From the list I drew up the following statement, 
giving the date of the establishment of the whole number of cottage 
hospitals extant in the United Kingdom at the end of 1892: 

1859 I 1871 18 1883 6 

i860 I 1872 13 1884 10 

1861 2 1873 13 1885 4 

1862 I 1874 8 1886 7 

1863 3 1875 8 1887 8 

1864 2 1876 8 1888 12 

1865 2 1877 4 1889 5 

1866 8 1878 7 1890 9 

1867 15 1879 8 1891 5 

1868 7 1880 7 1892 7 

1869 14 1881 5 

1870 15 1882 4 

Thus, while in the seven years 1859-65 the number of cottage 
hospitals opened was about two a year, in the seven years 1866-72 
the number was about 13 a year; in the seven years 1873-79 
the number was about 8 a year; in the seven years 1880-86 the 
number was just over 6 a year; and in the six years 1887-92 the 
number was just over 7! a year. 

The fact that the 7 years 1866-72 saw so many cottage hospitals 
established is exceptionally interesting. It has been explained as 
follows : 

In 1866 a little work on cottage hospital management was pub- 
lished by Mr. Harris and another by Dr. Waring ; a third edition of 
Mr. Napper's pamphlet was issued, and Dr. Swete brought the sub- 
ject before the British Medical Association, at Bristol. 

In 1869 or 1870 Dr. Swete's ** Handy Book of Cottage Hospitals" 
was published, and the extension of the movement was assisted by 
favorable notices in many influential papers. 



COTTAGE HOSPITALS. 337 

More recently a distinct stimulus was given to the movement by 
the Queen's Jubilee. In 1887 there were established 5 cottage hos- 
pitals; in 1888, 6 cottage hospitals, and in 1889 there was established 
I cottage hospital by means of funds collected locally to celebrate 
the Queen's Jubilee. 

It is worthy of note also how wide-spread has been the cottage 
hospital movement. There are now cottage hospitals in active 
work in all but three of the English counties (the counties of Hunt- 
ingdon, Monmouth, and Rutland), in all but two of the counties of 
Wales (Brecon and Cardigan), in ten counties of Scotland and in 
three counties of Ireland. 

Subjoined is a statement of the number of cottage hospitals exist- 
ing at the close of the year 1892, and the aggregate number of beds 
provided in each county : 

PntTumvc Number of Number of 

v.ouirriH. Cottage HospitaU Patients' bed* 

England : provided. therein. 

Bedford i 18 

Berks 8 84 

Bucks 5 42 

Cambridge 3 58 

Chester 5 85 

Cornwall 5 69 

Cumberland 2 30 

Derby.,.. 2 18 

Devon. 14 158 

Dorset 7 90 

Durham 5 84 

Essex 7 53 

Gloucester 9 82 

Hants 8 76 

Hereford.. 3 20 

Herts 6 56 

Kent 19 234 

Lancashire.. 7 99 

Leicester 2 11 

Lincoln 6 107 

Middlesex 10 97 

Norfolk 3 38 

Northampton i 6 

Northumberland i 16 

Nottingham 2 27 

Oxford 3 32 

Shropshire ,.. 4 40 

Somerset 8 96 

Stafford..... 9 192 

Safifolk 4 31 

Surrey 12 167 




33« 

Warakfc... 

r«rfc.. 

T«ttl ii EtiMrf, 115 MS3 

Waks: 
A.C1*. 
Cam 

FHu... 

'Mbroke.. 

TouliaWalM... 

Ayr. .. 

Elgta.. 
Ftfe^.. 

Rou.. 
Roxbsi^h. . 

Tecal u Scotland. . 

Auria. 
Dowo... 

London deny.. . 

Total In Ireland 3 

Total in the United Klngdon 147 3.064 

Thus is shown at a glance the spread of the cottage hospital move- 
ment. It has indeed extended to one of the Channel Islands, for in 
May, 1888, the Victoria Cottage Hospital was founded in Guernsey, 
providing 10 beds for patients, and the income last year was j£i755- 

Some Cottage Hospitals which have been dosed. 
Before remarking on some of the 247 cottage hospitals which have 
succeeded, it may be expedient to refer briefly to the cottage hospi- 



n 



COTTAGE HOSPITALS. 339 

tals founded during the same period which have not survived. I 
have not been able to obtain a complete list of these, but the follow- 
ing it is believed is proximately accurate: 

Year No. of 

when Name of Hospital. County. beds 

founded. provided. 

1861 Dinorwic Hospital Carnarvon.... 8 

1863 East Grinstead Cottage Hospital Sussex 7 

** Stockton Surgical Hospital Durham 8 

1864 Wrington Hospital Somerset 5 

1866 Crimond Cottage Hospital Aberdeen 

Great Bookham Hospital York 

King's Sutton Hospital Northampton . . 6 

1867 Charmouth Hospital Dorset 3 

Richmond Hospital York 4 

Stratton Hospital Cornwall 6 

1868 Alloa Cottage Hospital Stirling 15 

Alton Cottage Hospital Hants 7 

Knole Cottage Hospital Kent 

Litcham Hospital Norfolk 8 

Petworth Hospital r Sussex 8 

St. Andrew's Home, Weybread Snfifolk 12 

1870 Charlton Children's Home Wilts 10 

Chipping Norton Cottage Hospital Oxford 

Clearwell Hospital Gloucester .... 6 

Staple! ord Hospital Nottingham . . . 

Trowbridge Hospital Wilts 6 

Worksop Hospital Nottingham ... 5 

Yate Cottage Hospital Gloucester .... 4 

1871 Bovey Tracey Hospital Devon 6 

Copland Sodbury Hospital Middlesex 6 

Oxlinch Hospital Gloucester .... 8 

1872 East Kudham Hospital Norfolk 4 

*' Harrow*on-the- Hill Hospital Middlesex 8 

1873 Moreton Hampstead Convalescent Hospital. ...Devon 14 

Foston Cottage Hospital Stafford 3 

Hilston Hospital Hereford 5 

1876 Llangollen Hospital Denbigh 6 

*' Margate Cottage Hospital Kent 5 

1877 Purton Cottage Hospital Wilts 5 

Thus during 33 years, 34 cottage hospitals have been closed or no 
longer used as cottage hospitals. I have not been able to ascertain 
the number of beds provided by five of these hospitals; the aggre- 
gate number of the beds provided by the remaining 29 was 198. 

The reasons which led to the closing of these hospitals are various. 
For instance, at Wrington the surgeon was a churchman and the 
secretary a dissenter, and a discussion arose as to whether the 
patients when able should attend church or chapel, and this grew 



« 






t( 
** 
«< 
« 



«< 
«( 
II 
11 



II 
<i 



II 
II 



340 VACHER. 

into a quarrel, ultimately leading to the closure of the hospital after 
about five years' work. 

At Great Bookbam there seems to have been an animus against 
the hospital, for though only opened in 1866, it was closed as a hos- 
pital in 1868 and converted into an institution for providing nurses 
and sick comforts for the poor. 

Richmond Hospital was continued for 1 1 years in a cottage, the 
use of which was obtained for a nominal rent, when a large hospital 
was built by a lady and presented to the town, so that the cottage 
hospital was no longer required. 

Knole Cottage Hospital also appears to have done good work from 
its opening in 1868 till superseded by the hospital which was erected 
at Holmesdale in 1873. 

Stapleford is reported to have been discontinued owing to the 
advanced age of the founder and his disappointment in not securing 
the assistance of his nephew as surgeon to the hospital. 

Yate Hospital was closed after about 7 years of useful work, but 
its closing is reported to be through " no cause suggestive of failure 
of similar schemes." 

The Oxlinch Hospital, which was a farm-house adapted for use as 
a hospital, and furnished by a lady, was supported solely by the lady 
except that she charged the patients 6s. a week. It never appears 
to have been much used, being but four miles from Stroud, where 
there is a general hospital. 

The little hospital at East Rudham is reported to have been closed 
** because the poor thought that the medical man, whose services 
were gratuitous, derived some unknown benefit from the hospital.*' 

Hilston Hospital after some years* work closed and kept open the 
establishment as a dispensary for the treatment of out-patients. 

In the case of some of these hospitals the cause of their being 
closed could not be ascertained, and in many doubtless it was the 
difficulty in raising the required amount of funds. Some are stated 
to have been closed only temporarily. 

A Few Types of Existing Cottage Hospitals, 

I propose now to select out of my list of existing cottage hospitals 
a few types, not necessarily for imitation, but as fair samples of the 
whole. 

Grantham Hospital in Lincolnshire was erected in 1876 at a cost of 
;£5344, the furniture costing ;^8i2, and ;£i500 being given as an 
endowment fund. It is built of stone, occupying an excellent site on 



COTTAGE HOSPITALS. 34 1 

a hillside and commanding a good view. The two wards for male 
and female patients are placed as wings on either side of the admin- 
istrative block, and are large enough for 7 or 8 beds each. Remote 
from the main building is a small fever hospital, containing 4 beds 
arranged in two wards. A matron and 3 nurses form the nursing 
staff for the main building. The drains are all outside and efficiently 
disconnected and ventilated. On the whole it is perhaps the best 
and most satisfactory cottage hospital in the country. There is a 
separate laundry and mortuary. In-patients only are treated, and 
admission is free by letter of recommendation. Last year the num- 
ber of patients treated was 180. The income last year was ;Ci355 
and the expenditure ;£i2io. The cottage hospital is 22 miles from 
the nearest general hospital, the Lincoln County Infirmary. 

Beccles Hospital in Suffolk was erected in 1874 at a cost of ;£i500, 
the furnishing costing ;C300. The site, valued at ;Cioo, was given. 
There is no endowment It is a classic building, having a dispen- 
sary, waiting-room, accident ward, surgeon's room, matron's room, 
kitchen, etc., on the ground floor. On the floor above are two wards, 
30 feet X 16 feet, two wards 14 feet X 14 feet, and an operating 
room. The wards were originally fitted with 10 beds in all ; 13 are 
now provided. A matron and 2 nurses form the nursing staff. 
There appears to be no bath-room, laundry or mortuary. The 
closets are entered from passages without the intervention of cross- 
ventilated lobbies. Last year the number of in-patients treated was 
75. the number of out-patients 261. The income was £fi(>2 and the 
expenditure ;C496. 

Petersfield Cottage Hospital in Hampshire was erected in 1871 at 
a cost of ;^i4O0, the furnishing costing ;^234. It has a very small 
endowment. This little hospital is prettily designed in red brick; 
the situation being exceptionally well chosen, there is a pleasant 
country view from the windows. The sanitary arrangements are 
not well planned, and for many years after the opening of the hospital 
there was actually no bath-room. The accommodation for patients 
consists of two wards each 17 1 feet X I2i feet, and two wards each 
I2i feet X 10 feet. Originally 6 beds were provided for patients; 
there are now 8 beds. The wards are placed as wings on either side 
of the administrative block. There is an excellent, well lighted 
operating room. A mortuary is provided externally, but no laundry 
of any kind. Patients are ordinarily charged for maintenance at the 
rate of from 2s, 6d, to 8^. per week, but many are admitted free. 
Accidents are received without question at all hours. From 40 to 



342 VACHER. 

60 in-patients are treated annually. In the last returns published 
the income is entered at ^363 and the expenditure at ^433. At 
Ryde is a convalescent home in connection with this hospital. The 
cottage hospital is 17 miles from the nearest large general hospital 
at Porismouth. 

Berkhampstead Fever Hospital, Hertfordshire, was erected in 
1879 at a cost of ;^ai62, including the cost of building a boundary 
wall, making road and paths through the grounds and sinking a 
well. The site cost ^425 extra ; it consists of about 3 acres and has 
a frontage of about 144 feet on the highway. The expense of erec- 
tion, etc., was borne by the Berkhampstead Rural Sanitary Authority; 
the current expenses are also paid by the authority. The buildings 
as designed consist of two detached ward pavilions, communicating 
with an administrative block by means of a corrugated iron covered 
way standing on wooden supports, and also two detached buildings, 
one containing a wash-house, an ironing room, an ambulance shed, 
disinfecting room, and a storeroom for dry earth, ihe other being a 
mortuary. Only one of the detached pavilions has been built; it 
contains two wards 24 feet X 24 feet, a nurse's room, store-closet and 
moveable bath. Each ward has an earth-closet and sink cut off 
from the ward by a ventilating lobby. The buildings are of while 
and red brick and stand on a bed of concrete. They are roofed tn 
red tile. Each ward is well lighted with 6 windows, and each ward 
has an opening from the ceiling to the roof fitted with Boyle's venti- 
lators. The warming is by means of Gallon's stoves. The admin- 
istrative block is a two-storied building ; on the ground floor are 
sitting-room, surgery, kitchen, scullery, store, etc., and on the floor 
above two bedrooms. The water is derived from a well sunk into 
the chalk, raised by force-pump into a tank from which constant 
service can be provided. The sewerage is into a cesspit 350 feet to 
the north of the well, the flow of the spring in the chalk being from 
north to south. 

I might give particulars of many other cottage hospitals, but ihese 
will suffice as examples. Existing cottage hospitals indeed include 
many varieties. Some, like the hospital at Gorleston (Suffolk] and 
Winchcombe (Gloucester), provide but 4 beds ; others, e. g. Longton 
Cottage Hospital and Walsall Cottage Hospital, have 4a beds, about 
double the number first provided. 

Most cottage hospilals follow the lead of Cranleigh, being for 
severe medical and surgical cases; but four hospitals provide for 
infectious cases as well, and six are wholly for infectious cases, while 



COTTAGE HOSPITALS. 343 

three or four are for surgical cases only. One hospital receives all 
but phthisical cases, on^ is solely for children under lo years old, 
one is for patients having ulcerated legs or eczema, one is for hip 
disease and spinal disease, some are wholly or in part for convales- 
cents, one sets apart half the beds provided for lying-incases, several 
provide two or more cots for the treatment of little children. 

Many cottage hospitals have been commenced in old buildings 
altered and adapted for the purpose, and afterwards continued in new 
buildings. Many have been grafted, as it were, on previously existing 
dispensaries. Some have prospered from first to last and been able 
to gather an endowment fund from surplus income, some have had 
to appeal to the guardians of the poor to augment their subscrip- 
tion list. 

Finances. 

As regards income, many cottage hospitals are almost entirely 
dependent on voluntary contributions ; a few are wholly supported 
by their founders and publish no report, while a few are wholly or 
in part supported from rates levied by the local authority ; one is sup- 
ported entirely by railway workmen. Nearly all cottage hospitals 
charge for the maintenance of such patients as are considered able 
to pay. The charge ranges from is. to 21s, a'week, usually it is from 
2s. 6d, to 10s. 

Generally it may be said the income of cottage hospitals (with the 
exception of those provided for the treatment of infectious cases) is 
commonly derived from subscriptions and donations, church collec- 
tions, interest on money saved, or given or bequeathed as capital, and 
payments by patients or their friends. 

It is reckoned that, to keep up an interest in the hospital, at least 
half the income should be derived from local subscriptions. Thus a 
well managed cottage hospital usually derives about two-thirds of its 
income from subscriptions and donations. With the help derived in 
recent years from the yearly " Hospital Sunday," church collections 
may be counted on to provide a third of the remaining third ; there is 
therefore about two months to be made up by interest on capital 
and patients' payments. Of course, when a hospital is first opened, 
and for some years after, there is no capital, and the rule is to require 
a small payment for maintenance, from patients or their friends. 
The amount can be adjusted to the means and circumstances of the 
payer, and in special cases altogether remitted. In course of years a 
small capital from legacies, etc., is slowly accumulated, and many 
cottage hospitals have thus been placed in so good a financial posi- 



344 VACHER. 

tion that they have been able to do without maintenance charges 
from patients. Indeed, in some instances it is difficult to know what 
to do with capital. After the freehold of land and buildings has been 
purchased, and there is enough in hand to meet a year's expenses, 
probably the best use for interest from capital is to make the hospital 
free. This is certainly better than investing surplus income derived 
from interest and so increasing the endowment fund. 

It has been found that cottage hospitals, either large or small, 
taking one with another, can be supported at an annual cost of a 
little over £46 per bed provided, or ;^66 per bed occupied. This is 
certainly less than the cost of ordinary hospitals. 

Cottage hospitals for the treatment of infectious diseases are ordi- 
narily provided by the local sanitary authority, and should be 
maintained by the authority. They are thus more likely to be well 
managed than if provided and maintained by voluntary subscrip- 
tions, etc. Though it is usual to charge the patients or their friends 
maintenance fees of from 10s. 6d. to 14^. a week, it is not a wise 
practice. It is for the good of the community that every infectious 
patient who cannot be properly isolated should be sent to hospital, 
and every inducement should be held out to patients to get them to 
consent to their removal to hospital. 

Conclusion. 

As one who has founded a cottage hospital, and taken an active 
part in its management for 16 years, I may fairly claim to have some 
knowledge of the subject I am discussing. My experience in my own 
hospital, and a study of what has been attempted and done in respect 
of cottage hospital provision during the last third of a century in the 
United Kingdom, has naturally led me to some conclusions, and 
these I shall now state as briefly as possible. 

1. The term **cottage hospital" as used in this country means 
either : {a) A cottage or villa residence adapted and fitted for the 
reception and treatment of patients ; or, (^) a small hospital designed 
and built as such. 

The adapted building, though in some districts all that it is possi- 
ble to obtain, is never wholly satisfactory ; the specially constructed 
building, with the information at present available, may be arranged 
to fulfil all the requirements of a rural population as regards hospital 
accommodation. 

2. Cottage hospitals have been found well suited for the treat- 



COTTAGE HOSPITALS. 345 

ment of: (a) Severe medical and surgical cases, and (6) patients 
suffering from dangerous infectious disease. 

They have been also used, but not to any great extent, for the 
treatment of: (c) Obstetric cases ; (d) convalescents ; (e) patients 
suffering from some named disease, skin disease, spinal disease, hip 
disease, etc.; and (/) children. 

There is no reason to believe that there is any demand for special 
cottage hospitals such as these. Obstetric cases are better treated at 
home. A cottage hospital is no place for convalescents. Children 
should be admitted in all cottage hospitals. 

3. Cottage hospitals receiving severe medical and surgical cases 
are for villages and rural districts. If the nearest general hospital is 
8 or 10 miles away, and the population of the village and rural 
district within a radius of about 4 miles is 4,000 or 5,000, it may be 
assumed there is work for a cottage hospital providing from 4 to 6 
beds. 

4. The smallest cottage hospital should have at least 2 wards for 
patients, a matron's sitting-room, a medical officer's room or oper- 
ating room, 2 bedrooms, a kitchen, scullery and wash-house, larder, 
store-room, bath-room, two water-closets, fuel-house and mortuary 
external to the house. The drains should be laid outside the house, 
disconnected and ventilated, and each water-closet in the house 
should be cut off by means of a lobby having cross-ventilation. In 
rural districts where there are no sewers earth-closets may be pro- 
vided in place of water-closets. 

5. Every cottage hospital not having a resident medical officer 
should be within a very short distance of one of the medical practi- 
tioners connected with it. 

6. Every cottage hospital should be well warmed and lighted and 
have a good water supply. It should be a detached building, and the 
site selected should be at least dry and clean, fairly open and reason- 
ably accessible. 

7. If the hospital be for the treatment of infectious cases there 
should be space enough around it for the erection of temporary 
structures, such as occasion may require. The administrative offices 
should also be somewhat in excess of the permanent wards. 

8. The amount of air space per patient should not be less in 
ordinary cases than 800 cubic feet, and should not be less in infec- 
tious cases than 1,600 cubic feet. If practicable, each ordinary 
patient should have 1,000 cubic feet, and each infectious patient 
2,000 cubic feet. 








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UEBER DEN BAU VON KINDERKRANKENHaUSERN. 353 



UEBER DEN BAU VON KINDERKRANKENHAUSERN, 
ISOLIRUNG UND VERHUTUNG DER UEBERTRA- 
GUNG VON INFECTIONSKRANKHEITEN, VER- 
PFLEGUNG DER KRANKEN. 

Von Dr. Adolf Baginsky, 

Professor der Kinder heilkunde a, d, Universit&t Berlin* 

Die fortschreitende Kenntniss der Krankheitsvorgange, gefordert 
auf der einen Seite durch die theoretischen Hilfswissenschaften, 
insbesondere durch die Bacteriologie, physiologische Chemie und 
durch dieverfeinerte mikroskopische Technik, auf der anderen Seite 
durch die eingehendste klinische Beobachtung, kommt nicht allein 
dem heilenden arztlichen Wirken in dem Einzelfalle zu Gute, son- 
dern sie fiihrt auch zur Feststellung hygienischer Thatsachen, aus 
welchen praktische Nutzanwendungen im Grossen f iir ganze Bevolk- 
erungsschichten hervorgehen. In den hygienischen Einrichtungen 
der Neuzeit spiegelt sich so gleichsam der jeweilig errungene Stand- 
punkt medicinischen Wissens, und es ist unschwer zu erkennen, wie 
die ersteren von dem letzteren dauernd beeinflusst und umgestaltet 
werden. 

Istdiese Beobachtung schon an den den Culturmenschen zunachst 
umgebenden Dingen,an Haus- und Wohnungseinrichtungen, an der 
Art der Zufiihrung der wichtigsten Lebensbediirfnisse, wie Nahrung 
und Wasser, an den Einrichtungen zur Entfernung der Abfallstoffe 
u. dgl. mehr zu machen, so kennzeichnet sich doch die tief eingreif- 
ende Wirkung des Fortschrittes medicinischer Erkenntniss urid 
arztlichen Wissens nirgends mehr, als dort, wo es sich direct um 
Einrichtungen handelt, welche dazu geschaffen werden, hereingebro- 
chene Krankheit zu beseitigen, dieselbe von dem einzelnen Erkrank- 
ten zu heben und fur die Gesammtheit unschadHch zu machen. — Im 
Krankenhausbau in erster Reihe krystallisirt sich gleichsam das in 
dem Augenblicke errungene gesammte medicinische Wissen und so ist 
jedes neu errichtete Krankenhaus, in der Voraussetzung, dass es die 
hochsten Ziele verfolgt, und dass die fachwissenschaftliche Leistung 
nicht durch andere, heterogene EinflUsse beengt oder gar verdrangt 
wird, ein Markstein dieses Gesammtwissens. So kommt es denn — und 
es ist dies das Geschick auch des besten Krankenhauses — dass das- 
selbe, wahrend es in dem Augenblicke, wo es errichtet ist, das Ideal 



354 BAGINSKY. 

zu verkorpern scheint, gerade um deswillen, weil es, gegenuber der 
fortschreitenden Entwickelung der medicinischen Wissenschaft ein 
Stabiles, mehr oder weniger Unveranderliches reprasentirt, nach 
einer Reihe von Jahren veraltet, iiberflugelt wird, nicht mehr auf der 
Hohe der Zeit steht — So ist es ausserordentlich schwierig, ja un- 
moglich) das wirklich Ideale im Krankenhausbau zu erreichen und 
man wird sich stets damit zufrieden geben miissen, dasjenige erreicht 
zu haben, was nach der Gesammtlage der erreichten Kenntniss als 
das ideal Beste erscheint 

Wenn demnach in den folgenden kurzen Thesen gewisse Punkte 
fiir den Bau von Kinderkrankenhausern als Norm fixirt werden, so 
kann damit nur ausgedrlickt werden, dass dieselben dasjenige zusam- 
menfassen, was nach dem augenblicklichen Standpunkte unseres Wis- 
sens gefordert werden muss; von Hause aus aber wird zugestanden 
werden miissen, dass zukiinftige grosse, bahnbrechende Errungen- 
schaften in der Medicin nicht ohne Einfluss auf derartige Normen 
bleiben konnen. 

In diesem Sinne mogen also die folgenden Thesen aufgefasst 
werden. 

I. Bau und Einrichiunf;, 

1. Das Bediirfniss fiir specielle Kinderkrankenhauser ist gegeben 
durch die besonderen physiologischen und pathologischen Verhalt- 
nisse des kindlichen Alters, welchen in allgemeinen Krankenhausern 
gerecht zu werden kaum moglich, zum mindesten sehr schwierig ist. 
Die Altersstufen, fiir welche diese Thatsache Giiltigkeit hat, sind 
diejenigen von o — 12 Jahren, ausnahmsweise bis 14 Jahren. Inner- 
halb dieser Altersstufen sind die Kinder von 0—7 Jahren diejenigen, 
welche vorzugsweise die arztliche Hilfe beanspruchen, wahrend nach 
der 2. Dentition eine Zeit relativer Widerstandsfahigkeit gegen 
Erkrankungen eintritt. 

2. Sauglinge (Alter von o — i Jahren) gedeihen in einer Kranken- 
anstalt erfahrun'gsgemass am besten bei Darreichung der Mutterbrust 
(resp. Ammenbrust). Ein Kinderkrankenhaus, welches Sauglinge 
aufnimmt. soil daher so eingerichtet sein, dass auch den Saugenden 
Aufnahme gewiihrt werden kann. Die^e fast unabweisliche Bedin- 
gung wUrde dazu fiihren, die Sauglingsstation abnorm gross zu 
gestalten, und mit der Grosse der Abtheilung wiirden wegen der 
Schwierigkeit der Gestaltung normaler hygienischer Verhaltnisse die 
Gefahren fiir die jangste Altersstufe in gleichem Masse wachsen. 
Hier kann als wesentliche Aushilfe die ambulatorische Krankenbe- 



UEBER DEN BAU VON KINDERKRANKENHaUSERN. 355 

handlung eintreten. — Die Einrichtung einer Poliklinik ergibt sich 
also, abgesehen von anderweitigen Gesichtspunkten der Zweckmas- 
sigkeit, mit Riicksicht auf das Sauglingsalter als eine Nothwendigkeit 
f iir ein Kinderkrankenhaus. 

3. Eine besondere Stellung nehmen die an ausgesprochen conta- 
giosen Krankheiten leidenden Kinder ein. Es muss Fiirsorge 
getragen werden, dass die Uebertragung ansteckender Krankheiten 
verhindert wird. Dies geschieht durch moglichst voUkommene 
Isolirung sowohl der Kranken wie des Pflegepersonals. 

4. Fiir diejenigen Falle, welche einer contagiosen Krankheit bei 
der Aufnahme verdachtig sind, ohne dass noch eine pracise Diag- 
nose gestellt werden kann,bedarf es der Einrichtung einer Beobacht- 
ungsstation (Quarantaine). — Im Anschluss an die Quarantaine 
erscheint auch die Einrichtung einer Abtheilung fiir Kranke mit 
Mischinfectionen geboten. 

5. Demnach zerfallen die Einrichtungen fiir arztliche Behandlung 
im Allgemeinen, wie fiir Aufnahme und Verpflegung von kranken 
Kindern im Kinderkrankenhause in folgende Gruppen : 

a) Die Poliklinik (Einrichtung fiir ambulatorische Krankenbe- 
handlung) mit hinreichender Zahl von Isolirzimmern fiir ansteck- 
ende Krsmkheitsformen. 

U) Einrichtungen fiir Sauglinge mit nicht contagiosen Krankheiten 
(Sauglingsstation), mit Einrichtungen zur Aufnahme der Sau- 
genden. 

c) Einrichtungen fiir nicht contagiose Kranke in Altersstufen von 
1-12, ausnahmsweise bis 14 Jahren. (Indifferente Station in 2 Ab- 
theilungen zerfallend, medicinische (Jnnere) und chirurgische (dus- 
sere). 

d) Einrichtungen fiir contagiose Kranke aller Altersstufen von o 
bis 12 Jahren (Contagien-Stationen). Aufnahme der Sauglinge, wenn 
irgend moglich, mit den Saugenden. 

e) Einrichtungen fiir noch nicht bestimmbare, aber der Ansteck- 
ungsfahigkeit verdachtige Kranke (Quarantaine-Station). 

f) Einrichtungen fiir solche Kranke, welche an Mischinfectionen 
leiden. Die Abtheilung fiir Mischinfectionen kann mit der Quaran- 
taineabtheilung im Zusammenhang sein ; vielleicht wird es, weil die 
Quarantaineabtheilung das arztliche und Wartepersonal voraussicht- 
lich nicht hinlanglich in Thatigkeit erhalten wird, aus Griinden der 
Verwaltung stets geboten sein, beide Abtheilungen {e und /") an 
einander zu fiigen. 



•l" ■ 

m 

J 



i" 356 BAGINSKY. 

jl 6. Im Einzelnen kniipfen sich daran folgende Postulate: 

J tf) Dte Poliklinik. In dem Ambulatorium treffen contagiose und 

nicht contagiose Krankheitsformen zusammen. Die Gefahr der 
Uebertragung der Infectionskrankheiten von Kind auf Kind im 
Ambulatorium ist gross, ebenso gross die Gefahr der Einschleppung 
von Infectionskrankheiten in die stationaren Abtheilungen des 
Krankenhauses. Daher ist geboten, dass die Poliklinik von den 
stationaren Abtheilungen vollstandig getrennt ist, ferner dass in der 
Poliklinik hinlanglich getrennte Raume vorhanden sind, um die 
eingebrachten infectios kranken Kinder vom Augenblicke des Ein- 
trittes von einander getrennt zu halten. — In der Poliklinik begegnet 
man begreiflicherweise am ehesten denjenigen Krankheitsbildern, 
welche eine sichere Diagnose nicht zulassen. Daher ist die Verbin- 
dung der Poliklinik mit der Quarantainestation sehr naheliegend 
und die Unterbringung beider in einem Gebaude nicht unzweckmas- 
sig. Selbst die Leitung der gesammten Krankenaufnahme, auch 
fiir die stationaren Abtheilungen, durch die Poliklinik kann bei 
sorgfaltiger Trennung der Krankheitsformen als zweckmassig 
erscheinen. 

^) Die Sduglingssiatian wird aus den entwickelten Griinden nicht 
j zu gross zu gestalten sein. • 

\ c) Die Einrichtungen fiir die medicinUche (Jnnere) und die chir- 

urgische (aussere) Abtheilung (indifferente Kranke) konnen ohne 

Weiteres nach denjenigen Erfahrungen gestaltet werden, welche auch 

sonst auf dem Gebiete des Krankenhauswesens vorliegen. — Im Ein- 

J zelnen werden an den fiir chirurgisch kranke Kinder bestimmten 

Betten Vorrichtungen zu treffen sein, welche eine Verunreinigung 
der Verbande durch Ham und Stuhlgang moglichst verhindern. — 
Im Anschluss an die chirurgische Abtheilung wird auf Einrichtung 
einer orthopadischen Turnanstalt Bedacht zu nehmen sein, wahrend 
die innere Abtheilung ausreichend mit Tagraumen fiir reconvales- 
cente Kinder bedacht werden muss. 

d) Die Contagiensiationen, Der leitende Grundgedanke bei Ein- 
richtung der Contagienstationen muss die voUkommenste Isolirung 
der einzelnen Abtheilungen von den indifferenten und auch von ein- 
ander sein. Jedes Contagium hat sich als mehr oder weniger leicht 
iibertragbar auch auf seiche Kranke erwiesen, welche von einem 
anderen Contagium heimgesucht sind. Die fiir das Kindesalter 
wichtigsten Krankheitsformen, welche hier in Frage kommen, sind 
Diphtheric, Scharlach, Maseru, Keuchhusten, und in Landern mit 



i 

■1 

I 



UEBER DEN BAU VON KINDERKRANKENHaUSERN. 357 

mangelhaft durchgefuhrter Vaccination auch Variola. Jede dieser 
Krankheitsformen beansprucht sonach ein eigenes, von den iibrigen 
Gebauden getrennt stehendes Haus, mit Wohnungseinrichtung fiir 
Warterpersonal und Arzt, und Desinfectionseinrichtung fur den 
eintretenden resp. austretenden Besucher. 

e) Die Quarantainestatian, Dieselbe erheischt die Einrichtung 
einer gewissen Anzahl von Einzelzimmern, womoglich mit getrenn- 
tem Pflegepersonal fiirjedes Zimmer. 
• Dasselbe gilt fiir (/") die Kranken mit Mischinfectionen. 

7. Beziiglich Anlage der Wohnungen fur den arztlichen Leiter, 
den Verwaltungsvorstand, f Ur die Assistenten der indifTerenten Sta- 
tionen, die Apotheke, Bureaux, Waschkiiche, Kiiche, Warterinnen- 
wohnungen (mit Ausnahme derjenigen von den Contagienstationen) 
konnen im Wesentlichen die bisherigen, aus allgemeinen Kranken- 
hausern gewonnenen Erfahrungen zur Anwendung kommen. Nur 
muss beziiglich der Waschvorrichtungen die Sorge getroffen sein, 
dass die Wasche aus den Infectionspavillons (Contagienstationen) 
noch bevor sie in den allgemeinen Waschraum und in die allgemeinen 
Waschgefasse eingebracht wird, einem griindlichen, durchaus sich- 
eren Desinfectionsverfahren unterworfen wird. Zu diesem Zwecke 
kann die Wasche entweder in desinficirende Losungen \ — iji Subli- 
mat eingebracht werden und daselbst einige Stunden verweilen, bevor 
sie in das Waschhaus kommt, odersie mussvorherim Desinfections- 
apparat (am besten mit stromendem Wasserdampf arbeitend) desin- 
ficirt werden.* Fiir die Art der Einbringung der Wasche in den 
Apparat aus den Infectionsabtheilungen sind die allgemeinen jetzt 
geltenden, die Unmoglichkeit einer Verschleppung der Contagien 
sichernden Grundsatze der Hygiene geltend zu machen. In erster 
Reiheistdarauf Bedacht zu nehmen, dass die Wasche einen gewissen 
Grad von Feuchtigkeit hat, damit nicht Contagien durch Verstaub- 
ung verbreitet werden. 

Besojidere Sorgfalt erheischt die Anlage der Heiz- und Ventila- 
tionsvorrichtungen. Bei der Empfindlichkeit der kindlichen Respi- 
rationsorgane ist von der schwierig zu regulirenden Luftheizung 
vollig Abstand zu nehmen. Die Wasserheizung, allenfalls in Com- 
bination mit der Niederdruckdampf heizung ist als das vorziiglichste 
Heizsystem zu empfehlen. 

1 Hierbei macht man leicht die Beobachtung, dass die W&sche durch an- 
vertilgbare Flecken verunziert wird. 



358 BAGINSKY. 

Die Ventilation muss von der Heizung unabhangig sein. Am 
besten ist bei dem starken Luftbediirfniss welches in einem mit Con- 
tagien belegten Krankenhause vorhanden ist, und welches einen 
3maligen Luftwechsel pro Stunde voraussetzt, die Combination von 
Pulsionsventilation mit Aspiration, und wo dies zu kostspielig er- 
scheint, zum mindesten die einfache Pulsion. 

8. Die bisher entwickelten Anforderungen lassen die normale 
Gestaltung und die Leitung eines Kinderkfankenhauses nicht leicht 
erscheinen. Aus diesem Grunde darf ein Kinderkrankenhaus nidit 
zu gross angelegt werden. 250 — 300 Betten diirfte die ausserste 
Zahl der Betten sein, welche fiir ein einzelnes Kinderkrankenhaus 
einzurichten ware. 

9. Die Bemessung der Crosse der einzelnen Abtheilungen, insbe- 
sondere die Feststellung der Verhaltnisse zwischen indifferenten und 
Contagienstationen ist schwierig zu treffen und wird in jedem Orte 
nach den langjahrigen statistischen Erfahrungen zu machen sein. 

10. Die einzelnen Krankenzimmer miissen in Kinderkranken- 
hausern nicht fiir eine grosse Anzahl Betten eingerichtet werden. 
Die Einrichtung kleiner Krankenzimmer erschwert unzweifelhaft die 
Pflege und Ueberwachung, sie ist indess gar nicht zu entbehren, weil 
bei Ansammlung einer grosseren Kinderzahl in einem Saale die Un- 
ruhe einzelner Kinder sehr storend wirkt, iiberdies aber ist, insbe- 
sondece bei den contagiosen Krankheitsformen, eine Isolirung von 
Kindern durch die Art des Auftretens der Krankheiten sehr oft und 
weitaus haufiger geboten, als bei Erwachsenen. Zimmer fur 2 — 4 — 6 
in den Contagienstationen, bis 10 — 12 in den indifferenten Stationen 
sind entsprechend. Der Cubikraum pro Belt auf ca. 32 cbm, die quad- 
ratische Fiache auf 8 Quadratmeter (also bei 4 m Hohe) ist bei 
geeigneter Ventilation vollig ausreichend. 

11. Nach diesen Anforderungen ist der Baracken- oder Pavillon- 
bau das fiir ein Kinderkrankenhaus einzig geeignete System, mit 
der Einschrankung, dass fiir die Contagienhauser der langgestreckte, 
einstockige Pavilion, fiir die indifferenten Stationen und Poliklinik 
auch der zweistockige Pavilion annehmbar erscheint, und das gen- 
erelle Programm gestaltet sich sonach folgendermassen: 

a) Verwaltung ; Apotheke, eventuell auch Sauglingsstation als 
selbstandiger Bau, beliebig mehrstockig. 

d) Je ein i- oder 2st6ckiger Pavilion fiir die medicinische (innere) 
und chirurgische ('aussere) Abtheilung mit Operationsaal, Turnsaal 
(orthopadischem) und Tagraumen. 



UEBER DEN BAU VON KINDERKRANKENHaUSERN. 359 

c) Poliklinik mit reichlichen Isolirzimmern und Quarantaine (zwei- 
stockiger Pavilion). 

d) 5 Isolirhauser— je ein fiir sich stehender lang gestreckter ein- 
stockiger Pavilion. 

e) Haus fiir Centralheizanlage mit Desinfectionsapparat, Wasch- 
kuche, Kochkiiche und so weiter. 

y) Leichenhaus mit Sectionsraumen, Studienraumtn mit alien 
Einrichtungen, welche die Wissenschaft erfordert, insbesondere mit 
Einrichtungen fiir mikroskopisch-anatomische, bacterioiogische und 
chemische Forschung. 

Ueberdies Gartenanlagen in reichlicher Ausdehnung. 

11. V^rhiiiung der Uebertragung von Infectianskrankheiien, 

Es gibt vorzugsweise 3 Quellen der Uebertragung von Infections- 
krankheiten. — Die Mangel der Diagnostik und die so geschafTene 
Moglichkeit, infectiose Kranke direct mit anderen in Beruhrung zu 
bringen. — Sodann die Uebertragung durch Mittelspersonen (Aerzte, 
Pflegerinnen, Beamte, Besucher der stationaren Abtheilungen). — 
Endlich die Uebertragung durch Gegenstande. 

Die erste Quelle kann moglichst verstopft werden durch sorgfal- 
tige Untersuchung und ausgiebige Anwendung der Quarantaine. 
Absolut sichere Verhiitung der Uebertragung auf directem Wege 
wird aber nach dem augenblicklichen Stande unseres Wissens kaum 
mo^lich sein. 

Die Uebertragung durch Mittelspersonen kann verbiitet werden 
durch absolute Trennung des arztlichen Personals und der Pfleger in 
den einzelnen Abtheilungen. Ersteres wird nur sehr schwierig durch- 
zufiihren sein, weil es ein sehr umfangreiches arztliches Personal vor- 
aussetzt, welches meist nicht zur Verfiigung steht. Verstandniss fiir 
die einschlagigen Fragen und Gewissenhaftigkeit der Aerzte in der 
Desinfection wird indess diese Uebertragung auf ein Minimum redu- 
ciren. — Trennung des Pflegepersonals ist leichter durchfiihrbar und 
deshalb geboten. 

Besuch fremder Personen auf den Infectionsabtheilungen ist nur 
ausnahmsweise und unter besonderen Cautelen der Desinfection zu 
gestatten ; dann kann Einschleppung fremder Contagien durch 
Fremde verhiitet werden. 

Uebertragung durch Gegenstande ist durch sorgfaltige Desinfec- 
tion und strengste Reinlichkeit, die sich auf alle Gegenstande, wie 
Wasche, Geschirr, Apparate und so weiter, zu beziehen haben wird, 



360 BAGINSKY. 

zu verhuten. Reichliche Anwendung antiseptischer Losungen und 
Sterilisation durch stromenden Wasserdampf (Wasche, Kleidun^s- 
stucke) eventuell Vernichtung durch das Feuer (Abfall, Nahrungs- 
reste, Kehricht und so weiter) sind die Hilfemittel, die Uebertr^ung 
zu verhindern. 

III. Verpjlegung der Kranken. 

Die Verpflegungkranker Kinder istweitaus schwierigeralsdiejenige 
der Erwachsenen, well neben derjenigen Riicksicht, welche die Art 
und Schwere der KrankheitderErnahrungsartaufer]egt,,immernoch 
die Altersstufe der Erkrankten Beriicksichtigung erheischt, iiberdies 
aber Gewohnung und durch Erziehungsfehler geschafTenes Wider- 
streben der Kinder mehr als beim Erwachsenen zur Geltung gebracht 
wird; endlich beanspruchen einzelne Krankheitsformen besondere 
Ernahrungsart. — Die Combinationen, welche fiir das erkrankte Kind 
nothwendig werden, sind also weit mannigfal tiger. Man wird bei 
sorglicher Beriicksichtigung der erwahnten Momente zu folgenden 
Diatformen gelangen. 

1. Diat fiir Reconvalescenten von schwerer Krankheit und fiir 
fieberlose, an zehrenden (chirurgischen) Affectionen Leidende. — Es 
wird einem Uebermass von Nahrungsbedarfniss zu geniigen sein. 

2. Diat fiir chronische, nicht fiebernde Kranke, mit gewohnlichem 
physiologischen Nahrungsbediirfniss. 

3. Diat fur Kranke mit geringerem als physio) ogischem Nahrungs- 
bediirfniss unter besonderer Beriicksichtigung eines noch nicht vollig 
normal functionirenden Verdauungsvermogens. Es ist dies die Diat 
fiir massig fiebernde oder kiirzlich entfieberte Kranke im Beginne der 
Reconvalescenz. 

4. Diat fiir hochfiebernde Kranke. — Fieberdiat, wesentlich in fliis- 
siger Nahrung bestehend. 

Es handelt sich also zun'achst um Festsetzung von 4 Hauptdiatfor- 
men fiir alle Altersstufen. Lasst man nun die jiingste Altersperiode 
(Sauglingsalter selbst bis zur Mitte des zweiten Lebensjahres gerech- 
net) ausser Betracht, weil dieser Altersstufe durch hinreichende 
Milchzufiihrung unter Hinzufiigung von relativ geringen Mengen von 
Amylaceen GenOge geleistet werden kann, so werden in einem 
Krankenhause, in welchem Kinder bis 12 eventuell selbst 14 Jahren 
verpflegt werden sollen, immer noch folgende Altersstufen besondere 
Beriicksichtigung finden miissen. 

a) Kinder im Alter vom 9. bis 12. eventuell 14. Jahr. 



UEBER DEN BAU VON KINDERKRANKENHAUSERN. 36I 

b) Kinder im Alter vom Anfang des 5. bis Ende des 8. Lebens- 
jahres. 

c) Kinder im Alter vom li — ^4 Jahren. 

Es werden also jene oben erwahnten 4 Diatformen f iir jede dieser 
Altersstufen zu fixiren sein, so dass wir im Ganzen zu 4mal 3 Diat- 
formen gelangen. 

Nach den bisherigen, immerhin sehr wenig zureichenden Ermittel- 
ungen iiber das Nahrungsbediirfniss der Kinder in den verschiedenen 
Altersstufen ist es vielleicht gewagt, bestimmte fest begrenzte Nah- 
rungsmengen zu fixiren, und es wird der empirischen Handhabung 
ein ziemlich weiter Spielraum belassen werden mussen, bis die fort- 
schreitende Erfahrung auch hier sichere Normen kennen lehrt. Es 
muss dies namentlich aber fur das erkrankte Kind in Geltung bleiben 
und es muss darauf hinge wiesen werden, dass es eine der wichtigsten 
Aufgaben der modernen Kinderkrankenhauser wird, die fiirgesunde 
Kinder inaugurirten Ern'ahrungsstudien an Erkrankten und Recon- 
valescenten fortzusetzen. — Nach den vorliegenden Arbeiten von 
Forster, Camerer, UfTelmann u. A. wird man vielleicht wagen kon- 
nen, folgende Nahrungsmengen als die relativ richtigen fiir die 
erwahnten einzelnen Diatformen und relativen Altersstufen zu fixiren. 

I. Didtform, 

a) (Altersstufe 9 — 12 — 14 Jahren). Bediirfniss pro Tag 88.0 g 
Eiweiss4-6o g Fett + 260 g Kohlenhydrate. 

b) (Altersstufe von 5 — 9 Jahren). Bediirfniss pro Tag 70.0 g 
Eiweiss + so g Fett + 200 g Kohlenhydrate. 

c) (Altersstufe von li — 4 Jahren). Bediirfniss pro Tag 60 g 
Eiweiss4-45 g Fett+ 150 g Kohlenhydrate. 

II. Didtform, 

a) Bediirfniss pro Tag 70 g Eiweiss-l-50 g FettH-200 g Kohlen- 
hydrate. 

b) BedUrfniss pro Tag 60 g Eiweiss + 45 S Fett+ 150 g Kohlen- 
hydrate. 

c) Bediirfniss pro Tag 52 g Eiweiss-l-40 g Fett-f 125 g Kohlen- 
hydrate. 

III. Didtform. 

a) Bediirfniss pro Tag 65 g Eiweiss + sog Fett+ 165 g Kohlen- 
hydrate. 

b) Bediirfniss pro Tag 55 g Eiweiss4-45 g Fett+125 g Kohlen- 
hydrate. 

c) Bedurfniss pro Tag 40 g Eiweiss-l-40 g Fett+ 100 g Kohlen- 
hydrate. 



362 BAGINSKY. 

IV. Didtform. 
a) Bediirfniss pro Tag 60 g Eiweiss + 50 g Fett-f 150 g Kohlen- 

hydrate. 
d) Bediirfniss pro Tag 50 g Eiweiss + 45 S Felt +125 g Kohlen- 

hydrate. 
c) Bediirfniss pro Tag 42 g Eiweiss + 38 g Fett4-85g Kohlen- 

hydrate. 
Man erkennt sofort, dass II a) sich fast deckt mit I d), 

II d) " " " '• I c), 

so dass hier schon die Moglichkeit einer Reduction in der Zahl der 
Diatformen sich ergibt und vielleicht werden noch weitere Ein- 
schrankungen ohne Benachtheiligung sich mbglich machen lassen : 

Nach den Konig'schen Diattabellen wird es moglich, die vorge- 
schriebenen Werthe in soiche Nahrungsmittel umzusetzen, welche 
fiir die jeweilige Altersstufe und den jeweiligen, oben skizzirten 
Zustand der Erkrankten passen. 

Es wird hierbei darauf Bedacht zu nehmen sein, dass die jungeren 
Altersstufen ihren Eiweissbedarf in hervorragender Weise aus ani- 
malischer Kost werden zu ziehen haben und dass das Gleiche auch 
fiir die alteren Kinder gilt wenn es sich um Fieberzustande oder um 
soiche Zustande handelt, welche eine gewisse Riickstandigkeit der 
Verdauungsleistung voraussetzen lassen. Es wird dies insbesondere 
fiir die Diatformen III und IV in Betracht zu ziehen sein. — Zwischen 
Fetten und Kohlenhydraten wird,um einen etwasgiosseren Wechsel 
der Nahrung zu erzielen, in zwar nicht allzugrossem Massstabe, 
indess immerhin bis zu einer gewissen Grenze nach Massgabe der 
Calorien Vertretung stattfinden konnen ; allerdings darf nicht ausser 
Acht gesetzt werden, dass Kinder im Ganzen ein ziemlich reichliches 
Bediirfniss nach Fettzufuhr haben. — Im Einzelnen wird die Ver- 
theilung der Nahrungsmengen auf den Tag in den verschiedenen 
Landern nach Gewohnheit und Lebensweise verschieden sein. Fiir 
Deutschland erscheint es zweckmassig, 5 Mahlzeiten anzunehmen, 
davon sind 2 grossere, 3 kleinere, mit entsprechender Vertheilung 
der Nahrungsmengen. In dem Masse als die Kinder fortgeschritt- 
enen Altersstufen angehoren und ihr Aufenthalt im Krankenhause in 
fieberlosem Zustande sich verlangert, ist auf Wechsel in der Nahrung 
Bedacht zu nehmen. Nur die Sauglinge vertragen die Monotonie 
der Ernahrung, da Milch das Nahrungsbediirfniss fur lange Zeit bei 
denselben deckt. 



HOSPITALS FOR CHILDREN. 363 



THE UTILITY. PECULIARITIES, AND SPECIAL NEEDS 

OF HOSPITALS FOR CHILDREN. 

By William Wallis Ord, M.D. Oxon., M. R.C. P. London. 

Physician to Out-Patients at the Victoria Hospital for Children^ Chelsea, 
Physician to the West End Hospital for Nervous Diseases^ London. 

There has always been, both in the medical profession and out- 
side, a certain difference of opinion as to whether special hospitals 
can show a decided claim to a separate existence. In this country, 
certainly, most, if not all, of our special hospitals have originally been 
the outcome of individual benevolence, and it is still a moot-point 
whether in the present state of poverty of many of our great public 
charities any further advance in founding special institutions is 
advisable. Be this as it may, it is certain that many valuable insti- 
tutions of the kind exist in London and elsewhere, starting from 
small beginnings but in the end eventuating in great public boons. 

" Parva fuit, si prima velis elementa referre, 
Roma,'» 

may in truth be said of many of the hospitals of this land, and of 
none is it more true than of the special hospitals, and among them 
the hospitals for sick children are conspicuous instances: Many of 
these charities, started, as their histories tell us, in small and quite 
unsuitable tenements, have in the course of time become places world- 
wide in reputation not only as charities but as centers for research 
and the diffusion of knowledge. It has very truly been said that 
without special hospitals the rapid advance of science in the treat- 
ment of special diseases would have been seriously retarded. And 
this is most true with regard to children's hospitals. In most, if not 
all, of our great general hospitals in London there are departments 
for treating, and teaching on, diseases of the eye, the ear, the throat ; 
for the special diseases of women; for the treatment of the severer 
forms of venereal disease. And yet with regard to the diseases 
of childhood, more, far more, important to the community at large 
than any of these, for we are all children once, how little is or 
indeed, I may almost say, can be done in these institutions. True 
it is that in many of our general hospitals there are special wards 
for children, into which a certain number of comparatively chronic 



364 ORD. 

cases are admitted yearly, and which serve more or less as a ** show 
ward " when visitors are taken round the hospitals, but the amount 
of good that should be done in this direction is not to be measured 
in this way. In addition to the in-patient treatment we must bear in 
mind the exceedingly important out-patient department, and it is in 
this respect conspicuously that the general hospital fails. There is 
probably an out-patient department, which is open two or three 
times a week, under the care of a distinguished gynecologist, for the 
treatment of " women and children," but a single visit to one of these 
will show to what this admixture tends. The physician in charge is 
naturally anxious to obtain and impart knowledge in this particular 
line in which he is interested, and it comes about in process of time 
that this section of the out-patient department becomes the "depart- 
ment for women and children " with the children left out. 

With regard to the treatment of children as in-patients in a 
general hospital we are at once confronted with serious difficulties. 
The special wards for women cannot, of couse, be filled with cases of 
hip disease and cholera infantum. If the hospital be fortunate 
enough to possess a special ward for children, cases requiring parti- 
cular care — or operation — can, of course, be sent there. But even 
in such a case a children's ward in a general hospital is a focus of 
danger, and must necessarily be so. We shall see later how rife 
outbreaks of 2:ymotic diseases are in special children's hospitals. It 
is just as true a fact here and causes, if possible, a greater upset of 
general routine. But if such a special ward do not exist, then the 
children have to be taken into the ordinary wards with the adult 
patients. This mode of procedure is open to three serious objec- 
tions, from the point of view of the adult, from the point of view of 
the child, and from the point of view of the nurse. Nothing could* 
of course, possibly be worse than to have a squalling infant in a ward 
with a patient just coming round after a serious operation, or in the 
delirium of pneumonia or enteric fever. There are many people in 
health who cannot endure to be with children all the time. How 
much less then when they are afflicted with illness, acute or chronic? 
With regard to the children, too, it is evident that a certain number 
must be of an age to mark, learn and inwardly digest, and no less 
evident that, whether in the ordinary routine of the ward; or when, 
as they always do, they as convalescents become the pets of adult 
convalescents, they are exposed to the possibility of acquaintance 
with matters the knowledge of which it were at all events better to 



HOSPITALS FOR CHILDREN. 365 

postpone. Thirdly, it is notorious that children require special care 
and special nursing, and it would be necessary not only to increase, 
but also to modify, existing nursing arrangements in the wards of 
general hospitals, should the admission thereto of child-patients 
exceed a certain proportion. 

This, then, being a brief review of the method of treating children 
in general hospitals, let us turn to the other side of the question, and 
consider the advantages and disadvantages of special hospitals for 
children. The bugbear that meets us on the threshold is zymotic 
disease. If we take the history of one of our children's hospitals, we 
find that, in spite of the utmost care on the part of the staff, profes- 
sional and nursing, we have from time to time serious outbreaks of 
infectious disease occurring within the walls. Whether children are 
congregated together, or whether they are distributed in a certain 
proportion among adults, these diseases are bound from time to time 
to make their appearance, but it is evident that the outbreaks must 
be more severe and more difficult to cope with in the former than in 
the latter case. Infection is introduced in various ways. The patient 
may be suffering from an intercurrent disorder, for which he is 
admitted, and may infect the ward before the specific nature of his 
ailment is recognized. There may be an error of diagnosis, pardon- 
able enough, as I have had abundant means of knowing. But I am 
convinced that the greater proportion of infectious disease is intro- 
duced into the hospitals by the relations and friends, who may by the 
rules of the establishment visit them from time to time. The majority 
of outbreaks which I have come across in my own experience could 
be traced, by a process of exclusion, to this source. 

That this is the case, the authorities of one of our largest London 
hospitals, which possesses a special ward for children, are so con- 
vinced, that relations and friends are not admitted as visitors to the 
ward in the ordinary way, but are only allowed in if the patient's life 
be in danger. It is a serious question in my mind whether this plan 
might not be with advantage adopted generally in the case of chil- 
dren's hospitals. 

Another source of danger which can at all events in time be obvi- 
ated, but which still exists in some of the children's hospitals in this 
country, >w^ich, as 1 have shown above, exists in buildings not origin- 
ally intended for hospitals, but merely temporarily adapted for that 
purpose, is the existence of the out-patient department in the same 
building as the wards. Cases of infectious disease come to the out- 



366 ORD. 

patient department daily, of necessity, and, as they are bound to 
stay a certain time in the pari of building set apart for them, are thus 
liable to infect the whole. 

This danger of epidemics of infectious disease is really, as far as 1 
know, the only argument against congregating children together in 
a hospital entirely devoted to their charge. Let us now examine the 
other side of the question, and see what advantages such institutions 
offer, both to the patients and the doctor. 

I think there can be no doubt that children are happier in a ward 
by themselves than when mixed with adults. They see other children 
around them, a certain number able to sil up and play with their 
toys, and they thus soon learn to regard the hospital as a home, and to 
cease to pine after their relations. The disciphne, too, is better. Chil- 
dren in a general ward nearly always are spoiled, by being made the 
pels of nurses and patients alike. This of course is obviated when 
all are children, and the consideration has no mean bearing upon 
their future life. In the second place, the nursingof children, especi- 
ally those of tender years, is distinctly a branch by itself. Children 
require much more care in certain ways than adults, and the charge 
of them, though it may require for the moment a less amount of 
physical exertion, yet by the frequency and urgency of the calls 
renders the duly a most fatiguing and anxious one. With the nurse, 
as with ihe doctor, in a children's hospital, the fact that many of the 
patients cannot express their needs, sensations, or desires, induces a 
strain thai is not fell with the majority of adult patients. There are 
numberless^^///j soins thut are matters of daily routine in a children's 
ward, that would either be overlooked or a source of difficulty, and 
possibly of neglect, in another place. The mailer of feeding alone may 
be adduced in support of this view. The sterilization and artificial 
digestion of food carried on as a matter of course in a children's 
ward, would be a still further tax on the already too multifarious 
duties of a nurse in a general ward. 

From the point of view of ihe doctor, children's hospitals are a 
great boon. Apart from the fact thai by their existence he has a 
particular set of cases congregated together, 10 be utilized as may be 
for the purpose of learning and leaching, we must face the fact that 
little or no teaching is done in this special line in the gen(>ral hospi- 
tals, or at all events in the majority. There is one hospital in London 
where the most valuable and systematic teaching is given in this line 
in the wards, but in the majority it is neglected, mainly I think 




HOSPITALS FOR CHiLDREN. 367 

because those in charge of the out-patient departments do not 
^'weed'' the cases with discretion, their attention being naturally 
drawn to the more congenial points of adult disease, and hence it 
arises that the cases of disease in children admitted are, on the medi- 
cal side, cases of extreme urgency, not available in the majority of 
cases for the purposes of clinical instruction, and are apt, on the sur- 
gical side, to be cases of chronic trouble which do not lend themselves 
attractively to the process of demonstration by the bedside ; the 
number admitted in either case being of necessity comparatively 
small. Of clinical demonstration in the out-patient department 
there is, as I have said, little or none, and so the children's hospital 
becomes in consequence a happy hunting-ground to all who are pos- 
sessed of the belief that a knowledge of the diseases which our flesh 
is heir to at the most critical time of our life is essential to one who 
aspires to become a physician or surgeon in the highest sense of the 
word. And let me say here that it is not in the wards alone, or even 
chiefly, but in the out-patient department, that this line of study can 
be carried out to the greatest advantage. It is unfortunately true 
that hitherto here in London the vast fleld of clinical material pre- 
sented in the out-patient departments of our children's hospitals has 
been entirely neglected. But it is pleasant to learn that, under the 
extended curriculum now required by the General Medical Council, 
a certain amount of special attention to the diseases of children, both 
clinically and theoretically, is required, and I hope before long that 
our children's hospitals will take the place they should in our other- 
wise admirable system of clinical instruction in this country. 

On coming to the question of peculiarities and special needs of 
children's hospitals, we are confronted at once by the great question 
of nursing. It is a commonly accepted dictum that the successful 
issue of a case of enteric fever depends more upon the nurse than the 
doctor. I think that with regard to the special case we have in view 
we may expand this statement and say, that in the treatment of all 
diseases of children, good and reliable nursing is of primary import- 
ance, and that our success largely depends on it. Not only do chil- 
dren, and particularly infants, require constant and careful supervision, 
but they require more than this. They require to have around them 
persons who, if they cannot on all occasions anticipate their wants 
and wishes, yet must be able, either by experience or natural apti- 
tude, to recognize the signs and symptoms of wants and wishes which 
the patient in so many cases is unable to impart or explain. And in 






this respect the nursing of sick children la an arduous and anxious 
occupation. It is the practice, in this country at all events, to admit 
as nurses in children's hospitals women who would be disqualified by 
their youth from becoming nurses in general hospitals, and in ihe 
general hospitab themselves nurses are admitted as attendants in the 
children's ward, where it exists, at an earlier age than to the genera! 
wards. 1 suppose that this practice arose from the idea that a case 
ofa child is, in colloquial nursing parlance, a "lighter case" than that 
of an adult, and that, the wear and tear of the system being conse- 
quently less, women of less mature age and development might be 
with safety employed. Now for my part I believe that this is a fal- 
lacy. Doubtless the actual physical exertion of lifting patients, or 
assisting them to rise, of making and rearranging beds, and of minis- 
tering to their periodical requirements, is much greater when adults 
than when children are in question. But on the other hand we must 
take into consideration that in the case of children the calls are more 
frequent and more urgent, and that the sense of responsibihty which 
every nurse must feel is greatly increased in the latter case, and is a 
much greater strain mentally, and in a secondary manner corpor- 
eally, on a woman of 20 than on one of over 26 years of age. So that 
1 think that in children's hospitals, nurses should not be admitted too 
young. I have seen many cases of breakdown, some of them serious, 
others only temporary, which could be referred, at all events in part, 
to the age of the nurse. With regard to the numbers of the nursing 
staff relative to the number of beds in the ward, it is the outcome of 
experience in this country that children's wards must be much more 
strongly nursed from a numerical point of view than adults' wards. 
This is a natural corollary of what has been said above with regard 
to ihe needs and requirements of child- patients. The large number 
of the nursing staff in a children's hospital naturally must cause a 
great increase in the annual expenses. It would be imagined, a 
priori. thzt the average cost per head per patient would beverymuch 
less, in a children's than in a general hospital. This is in reality the, 
case, but the difference is so remarkably small as to be almost unap^ 
preciable. The average coal of each in-palieni in ten of ihe largest 
London hospitals is ^^6 \=,s.od., in the six London children's hospi- 
tals £,6 i2s. od. approximately. Of course the children's hospitals, 
from the fact that the number of inmates is small as compared with 
Ihe in-patients of a general hospital, would naturally have an in- 
creased cost per head, it being easier to treat a large number of 



I 



k. 




HOSPITALS FOR CHILDREN. 369 

patients at a less cost per head than a small number, but considering 
the saving that must necessarily be made in the way of food, dress- 
ings, etc., it is plain that there must be some source or sources of 
increased expenses in children's hospitals. This mainly arises from 
the absolute necessity, to which I have drawn attention above, of 
having a nursing staff proportionately larger than that of a general 
hospital. In fact, so much does the number of the necessary nursing 
staff increase the annual cost of the institution, that certain children's 
hospitals in this country do not admit as in-patients in the ordinary 
way children below the age of two years. How this extraordinary 
state of affairs came about originally I can hardly imagine. Cer- 
tainly I have never heard any medical man express an opinion in its 
favor. That this is the most critical period of the child's life I think 
may be taken from the following facts, viz: — that in the annual 
report of the Victoria Hospital for Children for the year 1892 the 
total death-rate was 13.3 per cent, while the death-rate of children 
below the age of two years was 75 per cent. And yet unless a child 
is practically moribund it is not admitted to the hospitals above 
referred to, with the consequent result that a small death-rate and a 
diminished cost of working per head can be announced in the annual 
report. Not only, in my opinion, is such a regulation absolutely 
unjustifiable, but I consider, on the contrary, that special attention 
ought to be given to cases of this age, and that where possible a 
separate ward should be provided for infants, with a numerous and 
specially adapted nursing staff. As so many of these cases are of the 
nature of gastro-enteritis and the like, it is evident that ample and 
efficient means for attending to the special requirements are abso- 
lutely necessary for the safety and well-being of the hospital at large. 
But the difficulty must not be shirked by excluding them from the 
benefits of the institution, but rather the capacity of the latter must 
be extended to meet their needs. 

With regard to the general construction of a children's hospital from 
an architectural point of view I have not much to say here, nor is it my 
province so to do. There is only one point which may be consid- 
ered, and that is the number of cubic feet per bed. In the case of 
adults, the necessary cubic space is variously estimated from 1,200- 
2,000 cubic feet, but about 1,500 or 1,600 cubic feet are probably about 
the average. Of course the amount may be much lessened in the 
case of children, but it may be taken that in a children's hospital, 
where the age may vary from one day to 1 2 years, the minimum 



*< <( 14 

it 11 (< 

i« *< II 



370 ORD. 

allowance should be 800 cubic feet per bed, and that 1,000 cubic feet 
would be more desirable. The following figures, extracted from Bur- 
dett's "Hospitals and Asylums of the World," give the cubic space 
per bed in some of the principal London children's hospitals: 

Great Ormond Street Hospital 919*92 c. f. per bed. 

East London (Shad well) Hospital 907.02 

Victoria Hospital, Chelsea. 833 

Evelina Hospital, Southwark 1096.2 

while in the provinces and elsewhere the figures range from 1,683 P^ 
bed at Pendlebury to 715.55 at Aberdeen. It is extremely necessary 
that ample and rapid means of ventilation should be provided, as it 
is evident that, especially in summer, evil odors are inseparable from 
the cases, by reason of the nature of prevailing ailments, the proper 
dispersal of which is absolutely necessary. The wards should be of 
such construction that the principles of natural ventilation may 
obtain, but this is of course not always possible in the cases where 
the building has only been modified for hospital requirements and 
not specially built for that purpose. 

I have here a few words to say with regard to diet and cooking. 
The dietary of children of the varied ages indicated already must of 
necessity vary considerably. Consequently, the preparation of food 
must necessarily be more complex in a children's hospital. It is 
quite possible to prepare the bulk of the food in a general kitchen 
supplying the whole hospital. But the cooking, and especially the 
preparation by means of artificial digestion, of food for special cases 
is best carried out by the nurses in the ward kitchen, which should 
have all the necessary apparatus for this object. 

Certain authorities, who are now taking the lead in bringing the pro- 
cess of hospital construction to a science, tell us that in all hospitals 
the out-patient department should be in an absolutely separate buDd- 
ing from that in which the wards are situated. This proposition is 
naturally more true in the case of children's hospitals than of others, 
owing, of course, to the danger of the introduction of infectious 
disease from the out-patient department to the main hospital, when 
they are under the same roof. Of course, sheltered means of commu- 
nication must exist between the two departments, but they should be 
practically isolated from one another. With regard to the out- 
patient department itself, there should be ample means therein to 
afford isolation to such cases as ,may require it. Every day cases 
of infectious disease come to the out-patient department of every 



HOSPITALS FOR CHILDREN. 37 1 

children's hospital. Certain of these ailments of the less severe type, 
such as whooping-cough and varicella, should be at once, on recog- 
nition, segregated from the bulk of the cases, until the requisite med- 
icines can be obtained, and they are removed by their friends. In 
the case of the more severe forms of infectious disease, such as 
scarlet fever or diphtheria, an absolutely isolated, well warmed, well 
ventilated and easily disinfected waiting-room must be provided for 
the accommodation of the case, until it can be removed in an ambu- 
lance either to a fever hospital, or in certain cases to its own home. 
Such a room should be so placed that while it is readily approached 
from the hospital, there is also ready communication with the street, 
so that in the process of conveyance to the ambulance, risk of 
spreading infection may be minimized. 

With regard to infectious disease in the main hospital I am of 
opinion that in London at all events, with its special hospitals for the 
reception of cases of fever of all kinds, no case of infectious disease 
in its acute stage ought to be taken into a children's hospital, with 
one important exception, and that is diphtheria. For this disease 
there should be in every children's hospital a special ward, con- 
structed for this purpose, and used for this diseasealone. A lengthy 
experience as a resident medical officer and, since then, as a physi- 
cian to a children's hospital, has shown me that a certain proportion 
of cases, varying according to the severity of the epidemic, must be 
treated within a very short time of the recognition of the disease, if 
any hope is to be entertained of their recovery, while in a certain 
smaller number removal to a fever hospital is practically, from the 
state of the patient, impossible. Such a ward must be ready for the 
reception of, and the necessary operations on, a case of diphtheria 
night and day. A few minutes' delay may mean death, a few 
minutes' gain by forethought and organization may mean safety. 
With regard to isolation-wards for the treatment of infectious dis- 
eases other than diphtheria there is, in London at all events, no neces- 
sity to provide them. They are bound to be in a way a source of 
danger, whatever proper precautions may be taken, and it is far 
better to send cases coming to the out-patient department or occur- 
ring in the wards to one of the recognized fever hospitals. It is, 
however, necessary to have a properly isolated ward into which 
surgical cases, which have been recently operated on, and which 
have contracted some acute specific fever, can be placed either until 
their surgical condition may admit of their removal to a fever 
hospital, or, in certain cases, until their complete convalescence from 



372 ORD. 

the fever. But such a ward must be used sparingly and with caution 
— only in cases of absolute necessity. I have heard it advocated 
that in children's hospitals there should be a separation-ward, in 
which cases of possible infectious disorder arising in the wards 
should be placed for a time until their exact nature is determined. 
I have seen such an experiment tried, and it was quite unsatisfac- 
tory. Cases of this kind must be settled at once, and delay in 
diagnosis only invites disaster. If once a habit is engendered among 
the resident medical officers of any hospital of regarding every case 
of rash as one of difficulty and doubt, farewell for the time to the 
efficiency of that hospital. Doubtful cases must of course arise from 
time to time. But in the majority of cases the symptoms are fairly 
prominent, and the diagnosis should be at once made. Proverbs are 
proverbially fallacious, but in the ordinary case of a suspicious rash 
the man who hesitates is lost. 

Finally, there is one adjunct that is absolutely necessary to make 
an ideal children's hospital, at all events in the case of one situated 
in a great city, and that unfortunately is beyond the means of most 
of them to supply. I mean a convalescent home, situated either in 
the country, or better, at the seaside if possible. Such a home 
relieves the hospital wards in three ways. First it takes a certain 
number of cases from the out-patient room which are not progress- 
ing favorably under treatment, either from non-hygienic surround- 
ings at home, or from want of proper care. Some of these cases 
would have to be admitted to the wards from time to time, and 
would increase the normal pressure. Secondly, cases of convales- 
cence from medical and surgical diseases can be sent away to the 
convalescent home earlier than to their own homes, and with much 
more benefit to themselves. Thirdly, it is well known that a number 
of cases are admitted to the surgical wards the state of whose health 
precludes immediate operation. These can be sent to the home and 
prepared for the ordeal, thus rendering the ultimate result much 
more hopeful, both from the point of view of the patient and the 
surgeon. 

The relief of pressure thus afforded to the parent hospital renders 
it a far more efficient agent for the treatment and relief of cases of 
urgency and danger than it could be possibly did it stand and work 
alone. 

In conclusion I wish to thank you, sir, and through you the mem- 
bers of the Congress, for the great honor you have done me in 
allowing me to bring this paper before you. 



CHILDREN S HOSPITALS IN AMERICA. 373 

CHILDREN'S HOSPITALS IN AMERICA. 
By Miss Mary L. Rogers, 

Superintendent Children's Hospital^ Washington^ D, C. 

In attempting to fulfil the request for a paper on this subject, diffi- 
culty has been found in drawing a proper line between, first, institu- 
tions for children partly of hospital, partly of asylum or orphanage 
intent; second, those manifestly for children, yet admitting certain 
classes of adults, notably of gynaecological and obstetrical service; 
and third, the hospital exclusively for children : all of which are 
constantly broadly classed under the title children's hospitals. 
Each has its own merit and interest, but to treat of all would lead to 
confusion. It has been decided to speak only of the hospital 
designed for sick children alone, and with one exception (the San 
Francisco Children's) the hospitals referred to are strictly of this 
class. 

These institutions have existed in America only during the last 
half of this century — indeed, have a history covering less than forty 
years. In 1850 appears almost the first literature upon the subject. 
A young dispensary physician in New York, writing under the title 
of Philopedos, sent out to the public an appeal for the lives of 
the children. He says that at this time there is no adequate 
place for the sick children in the general hospitals of the city, already 
overcrowded, and after a recital of their pitiful condition among 
the poorer classes, closes with a statement more emphatic than many 
pages of appeal, that in that year, of the entire city death-rate 81 per 
cent, were children under ten years. 

To the ordinary mind statistics do not form interesting literatui;e, 
but statistics such as this are impressive. And yet New York must 
have thought either that child-life was of little consequence, or that 
the building of hospitals was not the proper method for its preserva- 
tion, for little was done there until the establishment of St. Mary's 
Free Hospital for Children twenty years later. 

Philadelphia, in 1855, was the first to create such an institution for 
the exclusive care and treatment of sick children, and so little hold 
had it upon the public sympathy that it was opened with but twelve 
beds, — certainly a conservative number. 

The history of each succeeding effort has been a repetition of this 
small beginning, until the very last one is instituted. 



374 ROGERS. 

Boston came next in 1869, with the same service as Philadelphia, 
Washington in 1870 with six beds, and in the same year New York, 
already referred to, Albany in 1875 with two beds, San Francisco at 
the same time with four, Detroit in 1877 with twelve, and St. Louis 
in 1879 with ten. In New York the Laura Franklin was insti- 
tuted seven years ago, and emboldened perhaps by the successful 
growth of its predecessors, opened with fifty beds, the only large 
beginning of which we have record. Canada has a representative 
hospital of this class in Toronto, built and conducted upon the most 
modern methods. Two years ago Louisville fell into line, represent- 
ing in its hospital alone the entire work throughout the southwestern 
States. 

The ensuing history of each is curiously similar. Under adverse 
conditions, with discouragements innumerable, the start was made. 
No large private endowments nor munificent public appropriations, 
such as so often lift other institutions of the kind beyond financial 
care, even in their infancy; only the hand-to-hand struggle of the few 
who recognized the need and the pity of any little child suffering 
from illness without proper care. Children's hospitals in America 
appear to be structures founded and finished by faith and pennies. 

Another feature which strikingly presents itself, and which may 
very fittingly follow such a record, is that this has been in such large 
degree the work of women. 

Physicians appear from the first to have advised and approved the 
establishment of these special hospitals. The boards of directors 
or managers may often be largely composed of men, but the earliest 
reports in nearly every instance show the names of women who pro- 
vided the time, the zeal and the means for its establishment, and the 
latest reports as conclusively show that it is women who provide its 
yearly sustenance. 

The character of work done is on one line, acute general medical and 
surgical service. In the large number of personal letters of informa- 
tion from hospitals of this class we gain, first, that there is no provi- 
sion for admission of contagions. Of this feature of work it is only 
fair to say that it has not been merely disregarded by the various 
boards of trustees. The Philadelphia Children's Hospital, at great 
expense and infinite care, established a croup ward for admitting 
patients in the hope of successfully isolating and treating the malig- 
nant forms of throat disease, and were encouraged by most marked 
success, particularly in operative measures which would have been 



CHILDREN S HOSPITALS IN AMERICA. 375 

impracticable outside a hospital, owing to the lack of appliances for 
immediate emergency measures and of suitable after-care. After a 
short time, one or two years 1 think, the health board of the city 
ordered its discontinuance, much to the grief of the management. 
Others have spent much time and thought in attempting to 
arrive at a satisfactory arrangement, but with no permanent result, 
-except perhaps in one or two instances where the work has 
been continued. Whether contagion can be safely handled con- 
tinuously within the confines of a hospital with the highly suscepti- 
ble class of patients we have to treat is still a mooted ques- 
tion. At best it is to be feared that until the same rigorous absolute 
isolation can be made to exist in all departments, with medical 
internes as with nurses and servants while engaged in its care, it is not 
too much to say that there is danger in it, and that the results of 
experiment will scarcely be such as to encourage boards of man- 
agement to attempt it. Still, contagions form such an important 
feature in childhood diseases, they are so desperate in character in 
the large number of instances, they so particularly need the immedi- 
ate, unceasing, unrelaxing care of both physician and nurse such as 
cannot be found elsewhere than in the hospital, that it is with reluc- 
tance that the withdrawal of this service from the children's hospital 
is looked upon, if any safe means can be devised for the reception 
and care of this class of patients. Perhaps a ward in the form of a 
separate establishment adjunct to the hospital, controlled by it, but 
at a considerable distance, connected when necessary by ambulance 
with the hospital proper, may be the solution. Such a plan has been 
discussed by one of these hospitals recently, and only discarded 
because of lack of funds. Again, there are no wards for chronic or 
incurable cases, although many of these last two classes are taken as 
an act of special mercy for a limited time. Yet again, one hospital 
only (the Detroit), in a list of twelve comprising the largest in the 
country, admits infants. 

The outside age limit is from eighteen months to fourteen years, 
and in the greater number from two years to twelve. 

Is there not food for reflection in these facts ? In our cities, with the 
percentage they present of poor, whose conditions of life are those 
which foster these very chronic and incurable states in childhood, 
that no actual declared hospital provision is made for their ameliora- 
tion, and that even more, infants, whose danger in illness is greatest, 
can actually not get in. 



y 



376 ROGERS. 

Will the child's hospital, as it now exists, grow broader in its line 
of work as its position becomes more assured, and eventually afford 
asylum for these now abjured classes, or is it destined, itself now a 
specialty, to subdivide its own little people into specialties each in 
its own institution? It is early to prognosticate futurities for this 
interesting work, but the shadowy signs of the times point to the 
second conclusion. New York, the center of advanced hospital 
methods, has even now for its chilcfren an institution for orthopedic 
surgery, and another for infants alone, both successfully managed and 
supported, even while there already exist two general hospitals of 
the class. 

Whichever system may obtain, there is encouragement to believe 
that eventually all hospital care of children will be conducted in places 
designed for them alone. 

To enter into the detailed plans of conducting all the work of these 
institutions would be beyond the scope of this paper, but a brief 
report of one department maybe of interest to members of this Con- 
gress. Equally with other hospitals is the nursing growing to be 
regarded as of the greatest importance. At a superficial view there 
would seem to exist much less advance in this here than elsewhere, 
if lack of uniformity of method argues lack of advance. In truth, the 
nursing taken as a whole is in a somewhat chaotic state. No system 
has as yet been declared by general adoption as best. What this 
perhaps most truly argues is an appreciation of the peculiar nature 
of the work to be done, and the difficulty of fixing upon the best 
plan of conducting it. 

To illustrate: one hospital employs a superintendent and head 
nurse (graduate nurses) who supervise, while the nursing is done 
by untrained assistants ; and for serious cases trained nurses are tem- 
porarily employed. In another, one graduate nurse is regularly em- 
ployed; a certain fixed number of pupil nurses from a training school 
of the same city are taken for one month each, and the remainder 
are untrained assistants. In another, the house physician is head 
nurse, with experienced not-trained nurses under him. The Boston 
Children's has recently established a school for nurses under a sister- 
hood. The Washington co-operates with another special hospital 
for its nursing, while the Children's of San Francisco comes out 
strongly in the sole ownership of a well appointed school of thirty 
nurses governed upon the lines of the large training schools. 



CHILDREN S HOSPITALS IN AMERICA. 377 

Which system predominates? None. These hospitals are com- 
paratively so few and the nursing methods so varied that we might 
say each is unique unto itself. 

Which will predominate ? It is only possible to*say that no nurs- 
ing requires more intelligence, more system, more comprehension of 
the work than this. Those who have lived and worked in the midst 
of a children's service will follow me with appreciation of its truth. 
Children in disease are more often non-committal than otherwise. 
Even pain, grave in its meaning, unless of acute character, is passed 
over unless the eye is always seeing and the judgment unerring. 
The error that may be made because the nurse does not see what 
the little patient cannot tell, is too often followed by grave results. 
Whatever method secures to the nurse more power to care with gen- 
tleness and with skill, quickens her perceptions of pain and danger, 
gives her most science to apply to her work, that method will pre- 
dominate despite all difficulties. Twenty-five years ago a children's 
hospital which now stands pre-eminent in its broad ideas and advance 
of methods, offered a complete training and a certificate for sick-child 
nursing after a six months service in its wards, to girls not under six- 
teen years of age. It was. preferred, although not compulsory, that 
the applicants should be able to read. 

To-day we know that in child nursing we are undertaking one of 
the most delicate and difficult tasks of the profession, and that to do 
the work successfully the child's hospital miist, at whatever cost, 
have the best system and the most capable nursing. 

There is a question that is frequently repeated : Has this special 
hospital proved the best method of caring for the child, and are its 
advantages commensurate to the additional expense involved, over 
that of their treatment in the adult hospitals ? In reply might we not 
ask : Does not the drawing together of the large number give oppor- 
tunity for more comprehensive study of their diseases and of their 
best means of cure? Do we need more forcible argument thao that 
from the small beginnings we have now hospitals averaging a hun- 
dred beds, each showing constant healthy growth ; and that the 
reports of these institutions bear the names of the most distinguished 
men of the medical profession connected and identified with its work ? 
Do we not know here may exist conditions advantageous to the 
special patient not to be acquired otherwise? In these days of exact 
science physicians take into account all things which may influence 
the patient's condition, when not merely the administration of drugs 



X 



378 ROGERS. 

or the application of a surgical appliance is all that is considered in 
treatment of the sick. Children require certain surroundings and 
privileges with which to treat the adult would be unfavorable. The 
companionship of his kind does much to relieve home-sickness and 
the tedium of illness; the need of change in convalescence brings the 
playroom, the kindergarten, and the country home as adjuncts to 
the hospital. The child being the motive power, we study his par- 
ticular needs, his wants and the conditions under which he seems 
most content in sickness and most rapidly improves, and supply them 
because it is our work to do this particular thing ; until somewhere 
in the future the perfect sick home of the little child is formed, — a 
mosaic from the years of suggestions and trials and plans one by one 
conceived. 

A larger number of patients who need hospital care are obtained, 
than would be in the adult hospitals with an equal number, taken all 
together, of beds to receive them. Repeatedly I have been told by 
mothers that "they would bring the child where so many other chil- 
dren were, because he would not be lonely, but would never take 
him to a * big ' hospital.*' The natural shrinking from transmitting 
the child to the care of strangers in the case of many parents, the 
ignorance and oftentimes sad indifference of others, must all be con- 
sidered as factors in keeping the sick child at home, and whatever 
offers inducement to these to admit the child to the hospital cannot 
be too carefully considered. To have any work properly done, not 
cheaply done, is true economy. 

There is one further point only of which I would speak: the 
children's hospital as a possible economic factor in the common- 
wealth. Our annual national expenditure for the care and protection 
of our physically afflicted children is a matter of national pride. 
Witness the asylums for the deaf and the blind, and the homes for 
the cripple, built upon magnificent lines, supported by individual 
charity, by church and by state. Some part of these inmates are 
suffering from avoidable conditions. A celebrated oculist in Wash- 
ington told me that we are spending $15,000,000 every year to care 
for the blind, and that a large proportion of cases of blindness were 
preventable with proper and timely treatment; that his own experi- 
ences with neglected cases of ophthalmia neonatorum alone, resulting 
in total blindness, were the saddest part of all his work. 

The hospitals mentioned in this paper are an almost complete list 
of those in the entire country. The Louisville children's hospital of 



TOKYO CHARITY HOSPITAL. 379 

twenty-four beds, which has been referred to, is the sole hospital serv- 
ice'oniils kind in seven States. While these are doing to their 
uttermost extent, they are entirely inadequate to the need. One in 
New York publishes in its annual report that many times there will be a 
list of ten waidng^applicants for a bed in an operation ward. All state 
that the demand is generally in excess of the number of beds. Is it 
not wiser, considering these existing facts, to build more hospitals, if 
as a consequence less asylums of the other class would be required ? 
From a purely utilitarian standpoint, can we not better afford hos- 
pitals to cure the ills of childhood, and prevent the later and more 
pitiful necessity of places of refuge for the little victims of neglect, 
through, oftentimes, long lives of helplessness and suffering? ' 



TOKYO CHARITY HOSPITAL. 

Tokyo, Japan, May 17, 1893. 
Dr. John S. Billings, Chairman^ Third Section, 

Dear Doctor : — The history of the country tells us that charity institutions 
had been from time to time established since the reign of the Kimmei Junto 
(thirteen centuries ago) down to the first year of Manyen (i860), by the order 
of the Imperial House and Tokugawa family, mostly attached to the Buddhist 
temples, but I do not think worth to mention the details of them, — in fact, im- 
possible to get exact informations on them, from the want of minute records. 
Thirty-three years ago (i860) a hospital was established at Nagasaki accord- 
ing to an European model. It was, however, done so in paying system, and in 
late years, hospitals of a similar character have increased to several hundred. 
There was therefore no true charity hospital established till the year of 1882, 
when the Tokyo Charity Hospital has been instituted and is supported 
entirely by voluntary subscriptions. 

I at first meant to prepare a paper including hospitals of every kind of descrip- 
tions in this country, but failed to get materials from various circumstances — 
hence my desire to send to you a short description of the Tokyo Charity Hos- 
pital alone. Yours very sincerely, 

K. Takaki, F. R C. S. Eng., 

President of the Tokyo Charity Hospital, 

I. Orgajiization, A hospital committee was formed in 1881, and 
has organized the hospital by obtaining one hundred and thirty-six 
subscribers, and opened it in August, 1882. The hospital is patron- 
ized by Her Maj'esty the Empress since the year 1886. 



I 



t 
( 

I 
t 



380 TAKAKI. 

There is a committee consisting of ten ladies, specially appointed 
out of lady subscribers by Her Majesty the Empress, the president 
of which is the Princess Arisugawa. 

There are twelve medical and surgical consulting members, 
appointed by Her Majesty the Empress. 

The medical staff consists often members, with three house physi- 
cians and surgeons, all unpaid. 

II. Hospital Finance, The hospital is kept up by the interest of 
the fund 120,000 yen, voluntary subscriptions, and the income of the 
work done by the ladies' committee, such as bazar, art exhibition, 
etc. Cost for an in-patient about fifty sen, that for an out-patient 
about five sen a day. 

III. Wards. Two wards of two stories are built with bricks 
according to pavilion systeiji, and subdivided into rooms which can 
accommodate one hundred and twenty-two beds, though only sixty 
beds are at present made use of. , 

IV. Practically no paying patients. 

V. Two small wards are provided with six beds for contagious 
diseases. 

VI. Hospital dietaries and kitchens entirely in the Japanese 
manner. 

VII. An operating room built with wood. 

VIII. All washing done outside of the hospital, and bedding, 
clothing, etc., used for contagious cases disinfected by sending to 
the government disinfecting house. 

Table showing No. of in- and out-patients: 





In 


-patients. 


Out- 


-patients. 


Da 


ily average 










^ 


Vft 


AT tn^ ttnn 


Years. 


Number. 


Treatment days. 


Number. 


1 

Treatment days. 


out 


. 01 in- snu 
•patients. 


1882 


157 


6,657 


349 


13.525 




55 


1883 


211 


8,907 


862 


33.662 




116 


1884 


315 


17,102 


1,770 


48,654 




180 


1885 


3>S 


17,828 


2,659 


46,850 




177 


1886 


224 


13,121 


2,196 


35.285 




176 


1887 


368 


18,645 


3.645 


51.148 




191 


1888 


39S 


19,287 


4.293 


58,942 




214 


1889 


439 


20,162 


7.564 


79.132 




272 


1890 


463 


20,579 


6,163 


68,707 




244 


1891 


504 


19.363 


7,568 


95.340 




3M 


1892 


472 


18,306 


12,775 


93.283 




305 



A SHORT SKETCH OF THE CHILIAN HOSPITALS. 381 

Tokyo Charity Hospital Training School for Nurses, 

The school was established with a fund subscribed by volunteers 
in the year of 1885. 

The course of study for students, two years and a half. 

The subjects taught, elementary anatomy, physiology and nursing. 
In past eight years, one hundred and twenty-two students were 
admitted, of* which forty-seven have finished their course of study 
and obtained certificate after written, viva voce and practical exami- 
nations, twenty-two still studying, and forty-eight fell oflf. 

The trained nurses are well received by the public. 



A SHORT SKETCH OF THE CHILIAN HOSPITALS. . 
By Louis AsTA-BuRUAGA, M. D., Valparaiso, Chile. 

The hospitals in Chile are public institutions, partly supported by 
the government and partly by private charity. They have, never- 
theless, in their administrative organization, a semi-political and a 
semi-religious character, which can be best comprehended by having 
a knowledge of the form of government that rules this country. The 
information on this subject given by the following extract from a 
letter in the New York Herald of October 8th, 1883, will suffice for 
the purpose : 

*' To understand Chile as a political power it is needful to study it 
at Santiago, where two-thirds of the ruling families have palaces 
which they inhabit during the southern winter, spending the sum- 
mer, after the adjournment of Congress, either on great estates in 
the country or in villas at Vifia del Mar. Possessing wealth which 
makes it independent of toil for livelihood, this ruling class pursues 
politics as a profession. In every sense it is an aristocracy. It does 
not comprehend the practicability of a control of government by 
public opinion. There is no public opinion in Chile (unless it be on 
religious topics) except as it dictates."* 

Having read this statement, it will be easy to understand the 
system of hospital general administration prevalent in Chile, which I 
shall now proceed to describe. 

*Mr. Albert G. Browne's address to the American Geographical Society in 
1885 on The Growing Power 0/ the Republic of Chile, 





According to a bii! passed by the Chilian Congress in 1886, pub] 
charity in each department of the Republic was put in Ihe hands of 
Boards of Charity, called Juntas de Beneficencia. The magnitude of 
the work that each Board ox Junta has to perform can be calculated 
by a summary of the duties entrusted to its cares. These manifold 
duties are : to prescribe rules and regulations for the difierent insti- 
tutions under its charge, viz. service of hospitals, hospices, pest- 
houses, orphan, foundling and lunatic asylums, cemeteries, matemt- 
ties, dispensaries, etc., to determine the appropriate number of 
employees in said establishments, to fix their annual expenditures, 
to take charge of all moneys and properties of the corporation, to 
authorize the leasing, letting or selling of the real estate belonging 
to the same, to revise the genera! accounis, to accept or repudiate 
any legacies, donations and so forth with which charity is favored, to 
defend the interests of the corporation by going to law, to propose 
new buildings and approve their plans, to prescribe rules of hygiene, 
to organize a charity-treasury office and appoint clerks therefor, and I 
several other items too long to enumerate.* 

These Boards ox Juntas are composed of members elected part 
by the President of the Republic and partly by the cily muniej 
pality, and of the hospital administrators {adminislrador-es) who, 1 
first, were elected by the President of the Republic and subsequently! 
by the departmental Boards of Charity. 

Under such nomination one would naturally suppose that on]]^ 
influential political friends of the government or of the rulin 
were elected members of the different boards and hospital adminn 
trators: and such is really the case. No special requirements of «J 
technical kind or of scientific knowledge are needed to fulfil thttl 
membership duties of such boards, although there is a saying in\ 
Chile to the effect "that in order 10 become a member ai^ Junta i 
Benejicencia it is necessary to be old, rich and devout, "t and actually • 
it appears that, according to its present organization, no Other-J 
qualities are required. The names of a number of well-to-dvJ 
lawyers, farmers, merchants, statesmen and other minor politicd|f 
personalities figure among the list of members; but strangeljij 
enough, and what is most extraordinary, not a single medical t 

'Rtslamtntot para tat funtttt dt BiHt/.c^-ncta Jt l.i Rip-ltlka. Santiaga d 
Chile. iSSG. 

Alitibulcd to a celebrated physician in Santiago. 



^ 



A SHORT SKETCH OF THE CHILIAN HOSPITALS. 3S3 

nor any other individual with scientific atiainments is ever appointed 
to the board.* 

On account ot the mode of election and the peculiar composition 
of such managing boards, the vicissitudes of the political parties have 
much to do with the instability of hospital administration in Chile. 
When President Balmaceda was in power and had a strong opposi- 
tion party against him, he discharged from their posts all such mem- 
bers of the Boards of Charity as well as all such hospital physicians 
as did not uphold his political views; and in turn, when the Revo- 
lutionists made their triumphal entry in the Chilian metropolis, one 
of the first things that the new government did was to sweep away 
with all the managers and doctors belonging to the presidential party, 
and even many of those who, having taken no active part in the civil 
strife, did not side with the revolutionary party. ■' The spoils for the 
victors!" was the cry, and managers, doctors, and even orderlies, 
were dismissed from the hospitals in order to make room for new 
men. Naturally, midst such changes, the patients were the worst 
sufferers. 

Although charity in Chile is governed, in a great measure, by poli- 
tics, religion has also a share in its government. All (he hospitals 
are under the charge of Sisters of Charity of the Roman Catholic 
faith, and they generally direct the Administrator in hospital matters. 

The Administrator visits the hospital, sometimes daily, sometimes 
weekly, and goes through its diverse departments accompanied by 
the head nun or religious matron. He is to see that everything is 
kepi in good order, and all papers should be signed by him; his 
duties are not much above those incumbent upon a committee of 
inspection in an American hospital. His services are gratuitous. 

The Sisters, on the other hand, have charge of the general accounts, 
of the purchase of provisions, of the paying of salaries, of the super- 
vision of employees and the nursing staff, of the maintenance of dis- 
cipline, of the work in the drug -store and the supply of the same, of 
the care of the surgical instruments, etc. ; in one word, they have the 
entire control of al! the hospital management, in the very same manner 



* In fact, (here is a Epeciil clause ii 
paciuies hospilal doctors (rom holdii 
Sth article of the taid Kegulations. in 
cannot become members oE the boai 
empiojreeB o£ the eslablishment." W 
coiintry have hoapilal appDinlments . 
theni can become members of the Bos 



Regulations oE tbejunla (hat Inca- 
icc as members of the board. The 
h met;tion is made of all those who 
in its second clause. "All paid 
:as, all the most noted doclais in the 
arc paid for their services, none of 
of Charity. 








♦; 



,1 






7 384 ASTA-BURUAGA. 

as they bad in the Paris hospitals about a century ago. Consequent 

■■ with the aims of such religious congregations, they seem to attend 

more to the spiritual needs than to the physical demands of the 
patients. The very same abuses which led to the secularization of 

1] the Parisian hospitals may be seen here in full play, thanks to the 

i! unlimited authority vested upon the sisters. 

[; Thus politics and religion predominate in the management of 

Chilian hospitals, and science is very little or not at all consulted in 
their behalf; the consequence of such a state of affairs being that the 
hospitals in Chile are far below the standard reached by similar chari- 
table institutions in Europe and in the United States. 

f The medical board is practically a dead body. Its advice is rarely 

solicited, or not at all, in matters relating to the welfare of the hos- 
:' I pital, and any suggestions in that line made by it are generally treated 

*J with indifference and even contempt. 

'J The medical staff'is composed of several visiting or attending physi- 

• * cian-surgeons and one resident medical officer for each hospital. They 

i ' are appointed by the Board of Charity, upon recommendation of the 

! Administrator. 

] As no classification of cases is carried out at the hospital (medical, 

surgical, gynecological, puerperal and infectious cases being huddled 
together in the same ward), the doctors practice indiscriminately both 
branches of general medicine. Each visiting medical man has to 
attend a ward-service of from 26 to 36 patients, and is not assisted 
in his work by internes, as there are none, except the one just men- 
tioned (resident medical officer), who, in some hospitals, has under 
his charge six hundred patients during the greater part of the day 
and all the night. The visiting physician-surgeon makes his rounds 
in the morning, examining each case and prescribing accordingly. 
He receives a monthly fee, ranging from 30 to 50 paper dollars. The 
house medical officer is paid 250 paper dollars a month in the larger 
hospitals. 

No case-records are kept, outside of the statistical admissions and 
discharges registered at the office, under the care of the clerk. Not 
even in the hospital clinics is history-taking practiced.* Tempera- 
ture-charts are a luxury not to be seen in Chilian hospitals. 

*I claim to speak with authority on this subject, as I held the position, after 
a competitive examination, of assistant to one of the medical clinics of the 
University of Santiago. During the whole scholar year of 1890 I had the 
greatest difficulty in persuading the students to write out the anamnesis of the 
patients under their observation, and towards the end of the year I only sac- 



A SHORT SKETCH OF THE CHILIAN HOSPITALS. 38$ 

The nursing is nominally done by the sisters, who are paid ten 
paper dollars a month for their services, and they really act as over- 
seers of paid untrained orderlies and nurses. It is useless to mention 
that this department, so important in a well-managed hospital, could 
be vastly improved by the establishment of a training school for 
nurses. 

The outlay and purchasing of drugs, as well as their compounding 
and the preparation of prescriptions, are placed in the hands of the 
sisters, as was formerly the custom in Paris. There are no titled 
apothecaries in the hospital service. 

Finally, not a single hospital in Chile has a pathologist among its 
officers. 

In 1 89 1 there were seventy hospitals in all the Republic* Many 
of them possess incomes of their own, and besides receive subsidies 
from the government. In fact, all of them are helped by the state 
with more or less funds, the total amount yearly being 478,000 dol- 
lars in paper money (one dollar of Chilian money being equivalent 
now-a-days to about 30 cents American gold). Ships contribute 
yearly ten cents per ton to the maintenance <5f the hospital of the 
port they enter. Charity also adds to the income of these hospitals. 

All cases are received in the public hospitals free of charge ; in 
only one or two there are wards for pay-patients. 

1 here are in existence throughout Chile, besides the above-men- 
tioned hospitals, seventeen pest-houses, eight hospices, five foundling 
asylums, only one lunatic asylum and one maternity (both in San- 
tiago), and ninety-one dispensaries, upon all of which the state spends 
annually 257,000 paper dollars. 

Outside of the governmental hospitals and other state charities, a 
few private ones, mostly due to private enterprise, have been estab- 
lished, and thus in Valparaiso foreigners are treated in an English 
and a German hospital ; and furthermore, in Lota, a coal-mine district, 
a small hospital has been nicely fitted up by the mining company, in 
order to nurse therein the sick and wounded in their employ. 

A lengthy description of each individual hospital of Chile, as well 
as being beyond the scope of the present paper, would be unneces- 
sary, as a rough sketch of a few leading ones in Santiago and 

ceeded in collecting some fourteen histories from about one-half that number 
of students, the class numbering over twenty-five. 

*The accompanying data are taken from the Sinopsis Estadistica y Geogrdfica 
de Chile for 1891, an official publication founded by Mr. F. S. Asta-Buruaga, 
formerly Chilian Minister at Washington. "* 



386 ASTA-BURUAGA. 

Valparaiso will suffice to give an idea of all others throughout the 
country. 

Santiago, the capital of Chile, with 200,000 inhabitants, has four 
general hospitals, two of which are of comparatively modem .con- 
struction. 

The San Juan de Dios hospital was founded in 1556 by Pedro de 
Valdivia, the conqueror of Chile. It was destroyed by an earth- 
quake in 1647 and was reconstructed in 1702. The two-story build- 
ing with corridors which makes up its structure surrounds a square 
court. The wards contain from ten to thirty-six beds. The ventila- 
tion, which is effected by windows and ventilating outlets, is deficient, 
as the lower edge of the windows is at a high level and their upper 
edge does not reach the ceiling. The walls are whitewashed and 
the flooring is of pine wood. The wards have no service rooms, in 
regard to which commodity all Chilian hospitals are entirely desti- 
tute. No mess-room being at hand, the meals are accordingly dis- 
tributed to the patients in their wards, in consequence of which the 
emanations from the food diffuse throughout the atmosphere of the 
sick-room. Although most of the hospitals boast of a general bath- 
house, in this one, as in all others, there is a total absence of baths in 
connection with the wards. 

Only males are admitted to this hospital. On account of its central 
location a large number of the patients are casualty cases. 

The following table, taken from the report of the Junta of San- 
tiago for 1890-91,* gives an idea of the capacity and mortality of the 
institution : 

1890. 1891. 

Discharged, 3314 5604 

Died, 901 976 

In hospital, 256 287 



Total treated, 4471 6867 

Mortality, 20.3 per cent. 15.6 per cent. 

The San Francisco de Borja hospital for women was founded in 
1772, and its general features are about the same as those of the 
former. The buildings are old, although they have received some 
modifications of late. There is a maternity service connected with it. 

"^ Memoria del Presidente de la Junta de Beneficencia^ correspondicnte a 
1890-91. Santiago de Chile, 1892. 



A SHORT SKETCH OF THE CHILIAN HOSPITALS, 387 

The Statistics for the hospital are as follows : 

Discharged, 

Died, 

In hospital, 



1890. 


1891. 


7495 


6089 


1204 


1 102 


509 


469 


9208 


7650 


13.7 per cent. 


14.34 per cent. 



Total treated, 
Mortality, 

The San Vicente de Paul hospital was inaugurated in 1874. It 
is built on the one-story pavilion plan, but the buildings are so close 
together that each pavilion throws its shadow upon its neighbor. 
Twenty pavilions of from twenty-six to thirty-six beds are distributed 
over a small lot of ground. The long axis of the wards runs from 
north to south. In the wards there is a lack of ventilation and of 
light, on account of the small total superficial area of windows, a very 
common defect in Chilian hospitals. At both extremities doors open 
to the exterior, but the entrance of the back one is blocked up by a 
huge altar ; almost all hospitals, in fact, have altars instead of medi- 
cine-chests in the wards. The most expensive building in the 
hpspital is the chapel, which approaches the dimensions of a city 
church and is a decided hindrance to ventilation. 

Lately, six new brick wards have been constructed for clinical 
purposes, which will make the number of beds border on six hun- 
dred. Curiously enough, the axes of the new buildings run exactly 
in an opposite direction of the compass to those of the old pavilions. 
Why this innovation has been carried out is a problem difficult to 
solve, as the prevailing winds in this region come from the south and 
the climate is a temperate one. 

The San Vincente is generally considered the best hospital in 
Chile, although it is somewhat hampered by its situation, as the 
southern wind reaches it after passing over the whole city, and, 
furthermore, the general cemetery lies north of it, and near-by there 
are a medical school and a pest-house, and the only lunatic asylum in 
the whole country. 

In addition to its public character as a charity, this institution 
receives pay patients, it serves for clinical teaching, and is also a 
military hospital. 

The records of the San Vicente hospital give a much lower death 
rate than the two former hospitals, as the accompanying figures show : 



3«8 



59^ 7«H 

726 598 

In hospital, 535 558 



Total treated, 7250 8160 

Mentality, 10. i per cent. 7.32 per cent. 

The StUvador hosphaL This is a new hospital in process of coo- 
stmction ; but two wards ha%'e been opened to the poblic It is situ- 
ated in the outskirts of Santiago. I have not had an opportunity to 
visit this establishment, so that I cannot give a fair account of its 
construction. It is intended lor incurables, such as cancer and tuber- 
culous patients, although cases with acute diseases are also admitted. 

The statistics of this hospital show a frightful mortality, when we 
compare them with those of hospitals abroad intended :br the same 
purposes. The Royal Chest hospital in London gave for the years 
1877, 1878 and 1879 the following death-rate respectively: 10.9, 
12.7, and 1 1.9 per cent,^ whereas in the Salvador hospital the mor- 
tality raises between 27 and 30 per cent, as can be seen by the 
appended table : 

Discharged, 

Died, 

In hospital, 

Total treated, 
Mortality, 

In Valparaiso, which has a population of 120,000 inhabitants, there 
is only one state hospital for both sexes, that of San Juan de Dios. 

It consists of an agglomeration of buildings, old and new, in the 
midst of which there is a large chapel, situated at the foot of a 
hill, on the summit of which six wooden barracks for military 
patients are also clustered. The area of ground for the aggre- 
gate number of beds, which count almost six hundred, is very 
limited. About the same conditions hold in this hospital as in those 
o( Santiago, with the exception that Valparaiso, as a seaport, being 
somewhat of a cosmo{K>litan city, is more prone to accept new ideas 
and put them in execution, as far as political and religious interests 
allow. 

* Frederic J. Mooat : Organitation ef Medical Relief in the Afetr0p4lis^ P^g^ 
31 ; ia yLo^2XzsiASntW% Hospital Construction and Management. London, 1885. 



89 


90 


62 


75 


80 


82 


231 


247 


26.83 per cenL 


30.3 per cent 



A SHORT SKETCH OF THE CHILIAN HOSPITALS. 389 

Thanks to the enterprise of one of the hospital administrators,* a 
gentleman of English extraction and educated abroad, a pavilion was 
erected with two finely built wards, which have service rooms and 
well-conditioned water-closets. The long axis of the building is from 
south to north, in the direction of the prevailing winds. The wood- 
work in the wards is excellent, the walls are painted, the sash-windows 
(which are seldom seen in Chile) give a large superficial area of light, 
as they reach near to the ceiling, and the ventilator inlets and outlets 
being ample, are well calculated to admit a sufficient supply of fresh 
air in relation to the total cubic space of the ward. Each infirmary 
contains thirty-six beds. 

Another comparatively modern pavilion to be seen in this hospital 
is remarkable for the size of its wards. The dimensions of the upper 
one (there being two such wards, one over the other), which I took 
the pains to measure, are as follows : 

Length, 63.60 meters. 

Width, 8.10 *• 

Height, • 4.55 " 

Superficial area, 513. square meters. 

Volume, 2336.60 cubic meters. 

As the ward contains sixty-five beds, these figures give the follow- 
ing measurements for each bed : 

Lineal wall space, 1.90 meter. 

Floor space, 7.89 square meters. 

Volume of air, 35.84 cubic meters. 

There are seventeen windows on one side of the ward and thirteen 
windows and four doors that communicate with an open balcony on 
the other. At one end there is a door that leads into the scullery 
and to the water-closets. Erysipelas is endemic in these wards, 
which have not once been emptied or painted interiorly in six years. 

The statistical record of the San Juan de Dios hospital of Valpa- 
raiso reads as follows : 

1890. 1891. 

Discharged, 5245 5009 

Died, looi 1141 

In hospital, 581 561 

Total treated, 6827 67 11 

Mortality, . 19 per cent. 22.79 per cent. 

* Mr. Enrique Lyon, of Valparaiso. 



390 ASTA-BURUAGA. 

A short time ago, owing to the munificence of a wealthy charitable 
lady, a new hospital on the pavilion plan was erected in this port, 
but as it generally happens in Chile, the professional element was not 
duly consulted in regard to its plans, and the consequence was that, 
after an expense of an enormous sum of money and the costly 
and monumental building having reached completion, it was found 
to be inadequate for the purpose of attending sick people. The 
building has been lately handed over to a religious congregation to 
serve as an orphan asylum. 

In other Chilian cities the state hospitals are on more or less the 
same footing as those already described. Talca, a city in the inte- 
rior, has a fairly well constructed hospital, with brick-built pavilions 
laid' out in the form of an even-branched cross. The novelty which 
distinguishes these pavilions from other hospital buildings in Chile 
is that they are built slightly raised above the ground, permitting, 
thus, some circulation of air under the floor of the wards. 

In Iquique, the principal saltpetre exporting port of the Republic, 
there is a small hospital composed of wooden huts.^ 

Much more could be added to what I have already said about 
Chilian hospitals, but I am afraid the subject reads like ancient his- 
tory, and thus is not worthy of exciting the interest of modern scien- 
tific men, whose main aims are to seek the best means obtainable 
and arrive at the most efficient manner of rendering help to the sick 
poor. In studying these hospitals, no new suggestions, no new lines 
of conduct can be elicited from their present organization and con- 
struction, and the only conclusion that can be formulated in regard 
to them is that they urgently need a total reform. 

Allow me to state, in finishing up my remarks, that it would be 
most gratifying to me if some day I could see the hospitals in Chile 
basdd upon the same laws as the International Conference on Hos- 
pitals at Chicago may deem it proper to propose for the construction 
and management of charitable institutions. 

Valparaiso, May i, 1893. 



HOSPITALS AND TRAINING OF NURSES AT AMSTERDAM. 39I 



THE HOSPITAL CARE OF THE SICK AND THE TRAIN- 
ING OF NURSES AT AMSTERDAM. 

By Edward Stumpf, 

Medical Director City Hospital, 

If we limit the history of the origin of the hospitals at Amsterdam 
only to that which gave rise to the formation of the institutions now 
existing, we are obliged to go back even to the sixteenth century. 
We find mentioned in 1578 that the two hospitals existing at that 
time (the St. Peter and St. Mary hospitals) were removed to the nun- 
neries of the " oude en nieuwe nonnen," the nuns being driven away 
from their homes for that purpose. These nunneries were therefore 
the first origin of the general city hospital called " Binnen Gasthuis," 
which is still to be found in the same plac^. Being considered for 
that time an extensive building, it was appropriated to males and 
females and to medical and surgical patients ; it also contained, in , 
addition to the necessary buildings for administration, an institutibn 
for the shelterless. 

According to the municipal maps of Crommelin, the hospital was 
situated in the center of the city, and consisted of six buildings sepa- 
rated by gardens and canals. Each of these buildings was destined 
for diflferent classes of the sick, and also for patients suffering from 
contagious diseases. This was, however, altered soon, for in 1630 a 
new foundation was built, about a quarter of an hour out of the town, 
which was exclusively designed for imbeciles and infectious patients. 
Both remained united under one management, a board of trustees 
assisted by a physician as general governor. Ever since this prin- 
ciple of management has been maintained, so that both these hospitals 
are managed by one board. 

This management has to do only with general financial matters. 
The medical and nursing care of each of the institutions is entrusted 
to a medical director, who is assisted by a matron and house governor, 
respectively, as heads of nursing and administration. Although few 
alterations have been made in the management, many changes have 
been made in the building. If we compare their present plans with 
those of an earlier date, we find only a few subordinate parts which 
call to mind the former construction ; everything else has disappeared. 
Not to mention improvements and rebuildings of a temporary nature, 



392 STUMPF. 

we see now the ** Binnen Gasthuis " enriched in 1870 with an obstetric 
hospital for 50 persons; in 1875 with a surgical pavilion for 80 pati- 
ents; in 1880 with a surgical barrack for 30 women; in 1881 with an 
extensive building for laboratories and post-mortems, and in 1890 
with a large pavilion for 270 medical patients. Except the barrack 
for surgical females and the obstetric hospital, which are built accord- 
ing to the "corridor " system, all are built after the same principle, 
viz., buildings two or three stories high, with large wards at the end 
of each floor, while the middle wing is occupied by the smaller house- 
hold apartments (bathrooms, tea- kitchens, nurse dwellings, etc.). 
The so-called " Binnen Gasthuis " remained the longest unaltered. 
After being destroyed in 1730 by fire, it was rebuilt almost in accord- 
ance with the former plans, and not until 1889 was a new building 
erected. At this date, new pavilions, one for imbeciles, two for males 
and females, and three for infectious patients, were erected. The two 
city hospitals furnish altogether room for 1200 to 1300 patients. 
During the last hundred years we see, coincident with the extension 
of the city hospitals, new foundations erected by private initiative. 
In 1804 the Dutch Hebrew Board of Charity bought a house in the 
street called Rapenburg, to use for their sick. They stayed ihere 
until 1820, then removed to a military hospital, thence to a new 
building which was opened in 1830, and which was again left in 1840, 
till at last in 1883 the present new institution was occupied. In 1834 
the Portuguese Hebrew Board of Charity founded also a new hospital, 
to which only patients of the Hebrew religion were admitted. In 
1839 the Roman Catholic Church erected the St. Bernardus institu- 
tion, chiefly for the aged, but also available for nursing some patienis. 

In 1857 the *' Vereeniging von Ziekenverpleeging," which had ex- 
isted since 1844 (Association for Nursing), occupied a new building 
on the Prinsengracht, which in addition to being a home for the 
nurses was especially designed for the reception of patients. In 1865 
the building of the Children's Hospital was opened, which, commenc- 
ing with only 8 patients, extended steadily in the course of time, until 
there is at this moment room for more than 100 children. 

In a short time Amsterdam saw several more institutions arise, viz., 
the " Inrichting voor Ooglyders '* (Institution for Ophthalmic Pati- 
ents). In 1874 the "Roomsch Katholike Verpleeging" (the Roman 
Catholic Hospital) in 1878; while, owing to the initiative taken by 
Dr. Berns, a paying hospital was opened in 1879, which soon 
becoming too small for the many applications, was left for a new 



HOSPITALS AND TRAINING OF NURSES AT AMSTERDAM. 393 

building, the *' Burgerziekenhuis," which is constructed according 
to the most modern requirements (pavilion-barrack system), and 
furnished room for 145 patients. 

In 1889 Dr. Mendes de Leon opened his private hospital for 
women's diseases; in 1891 the "Vereeniging von gereformeerde 
Ziekenverpleeging !* (the Association of Protestant Sisters) was estab- 
lished, like in 1892 the ** Lulhersche Diaconnessen Inrichting" (the 
Home for Lutheran Deaconesses), the Institution for Psycho- 
therapeutics of Dr. Van Eden and Dr. van Renteghern, and the 
Institution for Pneumo- and Hydro-therapeutics of Dr. Arntzenius. 

In this enumeration are not mentioned the military hospitals, 
because they do not profit the commune of Amsterdam, but are 
central government asylums. Though all these institutions aim at 
the admitting of patients, the " Binnen Gasthuis," the " Buitengast- 
huis," the Children's Hospital, the Dutch Hebrew Hospital, the Insti- 
tution for Ophthalmic Patients, the Association for Nursing, and the 
Roman Catholic Hospital, can only be considered as real hospitals, 
because the others either have very limited room or make their main 
business nursing outside the institution. 

The management of the institutions differs. All agree in one 
respect, that a board of guardians has the supervision, except at the 
private hospitals of Dr. Mendes de Le6n and Dr. van Renteghern, 
which are managed absolutely by themselves, the difference being 
chiefly in the relation between the medical director and the board of 
guardians. Undoubtedly we fiild the greatest power of this board 
in the Association for Nursing, the Roman Catholic Hospital, the 
Association of Protestant Sisters, and the Home for Lutheran Deac- 
onesses, because there these boards have complete charge of the 
management, and because a medical director is wanting. The Binnen 
Gasthuis, the Buitengasthuis and the Dutch Hebrew Hospital form 
the second class. Here these boards are assisted by a medical 
director, who, participating with an advisory vote in the meetings, 
has the responsibility of the daily management, while the third class 
formed by the Burgerziekenhuis, the Institution for Ophthalmic 
Patients, and the Children's Hospital, where the medical director is 
a member of the board, and the whole management, including the 
financial part, is intrusted to him, but he is responsible to the board. 
As regards the means of support of these institutions, both the city 
hospitals and the Dutch Hebrew hospitals difler from the others. 

The Binnen Gasthuis and Buitengasthuis are the two official city 



394 STUMPP. 

hospitals. Every expenditure which cannot be covered by the nurs- 
ing rate is charged to the city, and this expenditure is consideraWe. 
As both the institutions are chiefly built for parish paupers, they are 
not proper for the admission of paying patients: so ihat the receipts 
are made up from patients who do not reside in Amsterdam, and by 
the payment of non-paupers who as accident cases are admitted in 
the hospitals, or for capital operations. That they are but a small 
proportion of the total number of patients is clearly indicated by tbe 
following table ; 

In i88t the paying patients of tbe total number were 6.7 per « 
.. ,g82 

" 1883 



1887 
1888 
1889 
1890 



6.3 
6.4 
7.6 



enl. 

I 



The expenditures which were charged lo the community 
Ainslerdam were; 



1883 ■• 

1884 " 

1885 " 



1889 
1890 
189 1 



■ 374.832 
' 359,276 

■ 373-589 
'471.319 
' 509,226 



. 261.530 
' 273,660 

■ 406,475 
* 423.115 
' 396,644 
" 18S6 " 387,869 

Besides this expenditure the community is obliged to contribute to 
the expenses of the Hebrew hospitals. These institutions are chiefly 
for the nursing of poor Jews, and the community makes an annual 
contiibuiion amounting to 65,000 florins. The uiher part of the 
expenditure of these hospitals is paid by the nursing receipts (9 
per ci-nt), legacit-s, donations, while the dtficic'iicy is paid by the 
Hebrew Board of Charily. In 1892 this parish subsidy amounted 
to fl. 30,000. These three are the only church hospitals enjoying 



subsidies fro 



1 the 



I aonation 



donations, legacies, rents, and payments of the jutie 



led by 
Most of 



HOSPITALS AND TRAINING OF NURSES AT AMSTERDAM. 395 

these institutions give opportunity for paid nursing at the following 
rates : 



Burgerziekenhuis. 






Associat' 


ion for Nurses. 


I St class fl. 10 








fl. 


7.50 


2d " " 7 








n 


5 


3d " " 5 








n 


2 


4th " "I. 


50 














Gynaecological 




Roman Catholic 


Institution for Ophthalmic PatienU. 


Hospiul. 




Hospital. 


1st class fl. 5 




fl. 


750 




fl. 5 


2d *• " 3 




ti 


5 




" 3 


3d " *• 2 




(( 


3 




" 1.50 


4th " '* 1.25 










free. 



The Children's Hospital furnishes free beds. In the Roman Cath- 
olic Hospital 40 patients are nursed without payment from the 
community. 

The construction of all these hospitals differs, partly owing to the 
influence of time, place and building, partly to the purposes for which 
they are used. The Buitengasthuis and the Burgerziekenhuis are 
the only ones which are built after both the pavilion and barrack 
systems. Similar to these are the two asylums where patients suffer- 
ing from acute infectious diseases (scarlatina, variola morbilli, typhus, 
cholera, etc.) are nursed. The other hospitals cannot admit them, 
except the Children's Hospital, which has isolating wards for conta- 
gious diseases. Imbeciles are only cared for in the Dutch Hebrew 
Hospital and the Buitengasthuis, while the Roman Catholic Hos- 
pital excludes women in childbed and venereal patients. The 
Association for Protestant Sisters admits only medical patients, and 
finally, the Home for Lutheran Deaconesses only medical female 
patients. The special hospitals, as the Children's Hospital, the Insti- 
tution for Ophthalmic Patients, and the Gynecological Hospital, are, 
as a matter of course, only accessible to patients suffering from the 
special diseases treated there. That frequent use is made of the 
different institutions is best shown by an enumeration of available 
beds compared with the total number of the days of nursing, each 
institution provides: Binnengasthuis, 600 to 700; Buitengasthuis, 
500; Burgerziekenhuis, 27 first, second and third class, 97 fourth 
class, 21 isolating beds; Children's Hospital, 85 and 30 isolating 
beds; Dutch Hebrew Hospital, no; Roman Catholic Hospital, 70; 
Hospital for Ophthalmic Patients, 5 first class, 8 second class, 45 



396 



STUMPF. 



third class ; Association for Nursing, 17 ; Gynaecological Hospital, 
12; Portuguese Hebrew Hospital, 21. 

The number of days of nursing during the last ten years was 
annually : 





Binnengasthuis. Buitengasthuis. Burgerxiekenhuis. 


Children's 
General. 


Honpital. 
uolAtiog. 


1882 


• • • • 


• • 


• • 




8,562 


• • • • 


• • • • 


1883 


159,036 


95 


,011 




9.959 


16,529 


1536 


1884 


I74»473 


III 


4»6 




10,247 


17.061 


4484 


1885 


172,243 


95.760 




9.955 


13.887 


3232 


1886 


171,786 


116 


►593 




10,868 


16,583 


3363 


1887 


178,376 


118, 


.169 




10,936 


17.817 


2898 


1888 


166,382 


130.541 




10,341 


19,076 


2366 


1889 


168,400 


»37 


,821 




11,520 


17.507 


3255 


1890 


206,305 


150.755 




11,766 


18,363 


3107 


I89I 


227.553 


167,380 




15.635 


14.632 


3326 


1892 


236,013 


160, 


386 




26,689 


21.559 


2925 




Dutch 

Hebrew 

Hospital. 


Roman 
Catholic 
Hospital. 


Associatioi 
for 

Nursing. 


\ Hospital for 
Ophthalmic 
Diseases. 


PortuRuesc 

Hebrew 

Hospital. 


Gyneco- 
logical 
Hospital. 


1882 


21.498 


10,158 




3050 


> 


> 




1883 

1884 


19.3*8 
21,628 


11,687 
14,191 




3021 
3076 








IS85 


27.385 


19,610 




2047 


2 w ** 

^^ n 3 







1886 
1887 


25,440 
29,006 


19,625 
21,501 




2351 
2974 


<S ») C0 

* tr. • ^ 


1^ 





1888 


25,410 


22,271 




2012 




ST 

C0 




1889 


28,294 


23,665 




2480 


*^ Cn**J rf 
^ ^^ ft 







1890 


33.»" 


23.497 




2516 


■" . • 

9^ vj 




I89I 


37.212 


• • • • 




3M7 


mm 




2500 


1892 


35.536 


• • • • 




4178 


^1 
(0 

• • 


• • 


2500 



Very different are the figures showing the length of residence per 
patient. We have thus : 









Burper- 


Children's 


Hospital. 




Binnengasthuis. 


Buitengasthuis. 


ziekenhuis. 


General. 


Isolating 


1883 


41 days 


76.1 


33 


52 


11 


1884 


34.79 


74-3 


35 


51 


15 


1885 


3565 


74.9 


29 


43 


16 


1886 


35.18 


69.5 


26 


45 


15 


1887 


33-21 


70.3 


28 


49 


13 


1888 


34.32 


69.8 


30J 


49 


11 


18S9 


36.64 


61.7 


29 


45 


13 


1890 


36-54 


70.7 


27J 


45 


9 


1891 


• 3992 


66.2 


29 


45 


10 


1892 


39-21 


62.2 


36 


40 


11 



HOSPITALS AND TRAINING OF NURSES AT AMSTERDAM. 397 





Dutch Hebrew 
Hospital. 


Roman Catholic 
Hospital. 


Hospital 

Ophthalmic 

Patients. 


Portuguese 

Hebrew C 
Hospital. 


Gynaecol 
Hospit! 


1883 

1884 


33j days 
31* 


53 
54.3 


> 


> 

< 


> 

< 


1885 
1886 
1887 
1888 


33^ff 
. 3if 
34 

34 


46.8 
46.8 

44.7 
44.1 


age: 

St class, 15 
cond class, 
ird class, 2 


9» 
(» 



• 


9> 

Oq 

ft 

? 



• 


1889 


31* 


40.7 


***** m 

• , . 00 






1890 


30» 


43 


• 






I89I 


35? 










1892 


33i 











The considerable numbers in columns i, 2, 4 and 7 are partly 
caused by the fact that as the patients do not pay they show no desire 
to be discharged, and partly because the physician needs to exercise 
care in the discharge of patients, because they are often obliged 
to resume very fatiguing work. A bad feature also is the want of 
institutions where chronic patients and convalescents can be admitted 
(the incurable are in part admitted to the municipal almshouse). 
The long residence in the Buitengasthuis is partly due to these 
general causes, but must chiefly be attributed to the long residence 
of the neuropathies, who form there one-quarter to one-fifth of the 
total number of patients. 

It is very difficult to compare the expenditure of the different hos- 
pitals. First of all, because the mode of calculation is so various. In 
the greater part of the institutions with class nursing, the medical 
side, the drugs, instruments, wine, etc., are paid separately, while in 
the hospital for parish paupers all expenses are reckoned in the per 
diem cost. It is a matter of course that in the large institutions, with 
extensive grounds, many pavilions, central warming and lighting, 
' and the greater number of the subordinated staff, the administration 
and the expenses for maintenance are higher than in the smaller 
ones; that in the imbecile hospitals, where the patients work, a con- 
siderable saving of expenses is made in the cost for wages, mainte- 
nance and repairs, while also the nature of the diseases has an influence 
through the cost of drugs, bandages and instruments. There is in 
the hospitals of Amsterdam in this respect such a difference that any 
comparison is impossible. To show this I give here some figures 
indicating the average per diem cost: Binnengasthuis and Buiten- 
gasthuis, fl. 1.34-1.20; Dutch Hebrew Hospital, fl. i ; Burgerzieken- 
huis, fl. 1. 1 2^-0.90 (only for food and medical assistance) ; Hospital 



398 STUMPF. 

for Ophthalmic Patients, fl. 1.74; Children's Hospital, fl. 1.03-1.40 
(isolating bed, 1.27-2.20) ; Roman Catholic Hospital, fl. 0.75 ; Gynae- 
cological Hospital, fl. 1.20. 

Binnen Gasihuis. — We find the largest medical service in the 
Binnen Gasthuis. The hospital is united with the university, and 
the professors are charged with the medical treatment of a part of the 
patients. There are therefore four medical sections divided among 
the professors as consulting physicians and the medical director, two 
surgical with two consulting surgeons, one obstetric, one gynaecolo- 
gical, and one for syphilis and skin diseases, each under its respective 
professor. These eight chiefs of the sections are assisted by one or 
two assistant physicians, all graduate physicians, twelve in all, who are 
residents in the hospital and not allowed private practice. Besides 
these twelve physicians there are added to the staff" two physicians 
in service of the first aid to the injured and one as prosector for the 
post-mortems. The latter works under the control of the professor 
of pathological anatomy. The twelve physicians who have charge 
of the treatment of the patients have each from 40 to 60 under their 
care. In the Buitengasthuis is a medical director who has the 
control over the treatment of all the patients, who are directiy 
entrusted to four assistant physicians, also resident in the hospital. 
Each physician has charge of about 100, including the insane and 
the neuropathies. 

Burf;erziekenhuis. — For the 125 patients nursed there are two 
house physicians, while the control over the medical patients devolves 
upon the medical director, and a consulting surgeon has charge of 
the surgical section. 

The Dutch Hebrew Hospital. — The medical director is resident 
in the hospital and head of the whole medical treatment, assisted by 
one non-resident assistant physician ; while for consultation there are 
one surgeon, one ophthalmologist and one gynaecologist. 

Hospital for Ophthalmic Patients. — The medical director (profes- 
sor in ophthalmology at the university) is assisted in the treatment by 
four ophthalmologists, all non-resident in the hospital, while two 
assistant physicians are at the institution, of whom one is resident. 
Such a numerous staff is necessary here because of the great number 
of out-patients who are treated in the institution. In 1892, for 
instance, there were 10,229 out-patients. 

Children's Hospital, — The treatment of the medical patients is 
entrusted to the medical director, that of the surgical to a surgeon. 



HOSPITALS AND TRAINING OF NURSES AT AMSTERDAM. 



39? 



Both have their residence next to the hospital. There are no other 
medical men. 

Gynacological HospitaL — The medical director is resident in the 
hospital and assisted by one assistant physician, also lesident in the 
hospital. 

In all the other institutions there are no resident physicians, so that 
the patients are treated either by their private physician as in the 
Association for Nursing, or by the physicians wTio, though they are 
not resident, visit the institutions at regular times (for instance, the 
Roman Catholic Hospital, which has three physicians). To sum up 
we have thus : 





PhyiiciBD.. 


i 


Aiilinni 

Hediul 
Dircclon. 


)' 


ll 




1 


1 

c 

1 


K 


1 
I 

s 


■EQ. 


Binnen asthuiB 


; 


7 
3 


4 
3 


4 


■ 


700 
500 

MS 

\ 

70 


55 








Dutch Hebrew Hospiwl 


' 


55 


Hoipital for Ophthalmic Patients.. 

Gfiizcological Ho»pita1 

Koinan Catholic Hospital 

Portuguese Hebrew Hospital 


i 



To compare the very different reports relating to nursing so as to 
give a good idea of them, it is necessary to distinguish between those 
institutions whose nurses nurse only in the hospital and those which 
furnish nurses outside the hospital. 

To the first group, where all the nurses are for the service of the 
admitted patients, belong the Binnen Gasthuis, the Buitengasthuis, 
the Burgerzlekenhuis, the Dutch Hebrew Hospital, the Hospital for 
Ophthalmic Patients, the Children's Hospital, and the Gynsecological 
Hospital. The above institutions agree in that they have exclusively 
lay-nursing, — in the first mentioned, mixed male and female nursing, 
while in the three last there exists only nursing by women. That at 
the present time all these institutions can supply a sufficient number 
of women of some cultivation and education, to satisfyihe numerous 
demands for nurses without being obliged to resort to the Roman 



400 STUMPF. 

Catholic Sisters or the Deaconesses, Amsterdam owes in great part 
to the Association of the " White Cross." 

Since the "White Cross Association" began in the year 1878 to 
work to improve the hospital nursing, it fulfilled this voluntary duty 
so well, we can state with confidence that the hospitals in our city of 
Amsterdam possess an excellently trained nursing staff. If we limit 
our report to what prevails at present in Amsterdam, the arrangement 
is as follows : From^he total number of applicants they take, as far as 
possible, women of cultivation who come as probationers to the four 
great hospitals. They reside there, receive all instruction free of cost, 
and are paid a moderate sum (about A. 1 25). The medical director 
assisted by the matron has charge of the training. While the director 
in these institutions gives theoretical lectures — anatomy, physiology, 
hygiene, general nursing (special lectures on lung, heart and digestive 
diseases, nursing of contagious diseases of childbed and children, sur- 
gical nursing and aseptics, first aid to the injured, laying out corpses, 
etc.), the matron assisted by her staff nurses devotes herself to the 
practical training of the nurses. After having followed courses of 
lectures for about a year, the probationers are promoted to jiurses, 
and after two or three years their training is considered to be 
finished. The nurses can then, after successful examination, leave 
the hospital to join one of th^ associations for private nursing. 

The city of Amsterdam regards this training very favorably. The 
doctors of the four chief hospitals have united in a common standard 
of training and examination, so that in the course of time Amsterdam 
will possess a large number of excellently trained nurses who have 
had a uniform training. The condition has not long existed. 

About ten years ago Dr. Van Deventer opened his first course of 
lectures, assisted by Dr. Blocker. Somewhat later, in 1884, Dr. 
Zegers followed with his lectures in the Binnen Gasthuis, while at 
last Dr. Stephan opened in 1892 the first regular course in the Bur- 
gerziekenhuis, and Dr. A. Courie one in 1892 in the Dutch Hebrew 
Hospital. In the other institutions mentioned above they have not 
these courses, because they get their nurses from among those 
trained in the four hospitals, and because the directors with their 
matrons can satisfactorily train the few women required for special 
nursing (children, ophthalmology, and gynaecology in their insti* 
tutions. 

When nurses have been employed for a long time in the institution 
and distinguish themselves, they are promoted to be staff- nu rses. 



HOSPITALS AND TRAINING OF NURSES AT AMSTERDAM. 4OI 

The general arrangement is to place a stafT-nurse at the head of 
each section, to have charge of the nurses and the further practical 
edjication of the probationers. All are inmates and have everything 
without payment, and receive fl. 125 to 525, according to their rank. 
The number of active nurses in the different institutions is as follows : 

Nurses. 





Number 
of Beds. 


Staff 
Nurses. 


xst class. 


A 

3d class. 


Proba- 
tioners. 


Man Nurses 

and 

Male Servants. 


Binnengasthuis, 


700 


11 


10 


39 


35 


23 


Buitengasthuis, 


500 


3 


6 


23 


25 


8 


Burgerziekenhuis, 


MS 


3 




28 




2 


Dutch Heb. Hospital, 


no 


2 




9 




5 


Children's Hospital, 


"5 


I 




20 






Hos. for Ophth. Patients, 58 


• 




4 






Gynaecological Hospital 


. 12 


« 




3 






Portuguese Hebrew Hos 


>., 21 






2 




2 



The nurses are commonly distributed as follows : In the Binnen- 
gasthuis there is i nurse for 8 adults or 6 children ; Buitengasthuis, 

I nurse for 8 adults; Dutch Hebrew Hospital, i nurse for 17 adults; 
Children's Hospital, i nurse -for 6 children ; Burgerziekenhuis, i 
nurse for 6 adults; Plospital for Ophthalmic Patients, i nurse for 14 
adults; Gynaecological Plospital, i nurse for 4 adults. 

These numbers refer only to the day service. The nurses in 
rotation are also charged with the night duty, lasting in the Binnen- 
gasthuis 12 hours, from 8.30 p. m. until 8.30 a. m. ; in the Buiten- 
gasthuis, 12 hours, from 8.30 p. m. until 8.30 a. m. ; in the Burger- 
ziekenhuis, II hours; in the Dutch Hebrew Hospital, 10 hours, from 

II p. m. to 9 a. m. ; in the Children's Hospital, 8 hours, from 10 
p. m. to 6 a. m. 

The Portuguese Hebrew Hospital and the Hospital for Ophthal- 
mic Patients hare no regular night service, as also the Gynaecological 
Hospital, but one of the nurses sleeps near the wards and can easily 
be called. 

The term of night service of a nurse is in the Binnengasthuis i 
week and after that at least 2 weeks of day service; in the Buiten- 
gasthuis, I week and after that at least 2 weeks of day service ; in 
the Burgerziekenhuis, i week and after that at least 5 weeks of day 
service ; in the Dutch Hebrew Hospital, i week and after that at 
least 2 weeks of day service ; in the Children's Hospital, thrice a 
week during 3 weeks of day service. 

As has already been mentioned, there is, in addition to the nurses, 



402 STUMPF. 

a male nursing staff in the general hospitals, because all the patients 
are not nursed by women. The exceptions made are not the same 
in all the hospitals. The following are not nursed by women : In ' 
the Binnengasthuis, i. the venereal males; 2. a part of the surgical 
males ; 3. bathing of all the admitted males. In the Buitengasthuis, 
I. the venereal males ; 2. a part of the male imbeciles ; 3. bathing of 
all the admitted males. In the Burgerziekenhuis, i. bathing of all 
the admitted males ; 2. assistance at some operations undergone by 
males. 

In the Dutch Hebrew Hospital and the Portuguese Hebrew Hos- 
pital the women nurse only females and children under 12 years. 

As indicated by the above mentioned, these hospitals agree in 
their requirements for nursing. They are absolutely different from 
those which, beside hospital nursing, furnish nurses outside the hos- 
pital. To this group belong from the hospitals mentioned in the 
beginning, the Association for Nursing, the Roman Cathplic Hos- 
pital, the Association of Protestant Sisters, and the Association for 
Lutheran Deaconesses, and the St Bernardus Hospital, while the 
" White Cross Association " and the Congregation of the Friars of 
St. John de Deo must also be added to it. 

The nursing staff in these institutions belongs for the greater part 
to different clerical orders. We have thus in the Roman Catholic 
Hospital, the St. Bernardus Hospital, and the Congregation of Friars 
of St. John de Deo, Roman Catholic sisters and friars, in No. 4 
Lutheran sisters. In No. 3 the sisters are under the clerical control 
of the Reformed Church. In No. i are only admitted sisters of 
Protestant religion, while the "White Cross" has lay-nursing. The 
exigencies of training differ very much. The " White Cross" resem- 
bles most nearly the first group. This association formerly gave 
its own courses of training, but has ceased to do so. ^The instruction 
given by the training schools in the hospitals being more complete, 
these separate courses had no reason to exist any longer. They 
were therefore given up, and the training of nurses was absolutely 
left to the hospitals. The committee of examination of this associ- 
ation is now formed of the directors of the hospitals at Amsterdam, 
so that the requirements are the same as in the hospitals ; two or 
three years of hospital service and a scheme of instruction conform- 
ing to that of the Amsterdam hospital nurses are required. This 
association is in reality mainly composed of nurses formerly active in 
the four great hospitals. 



HOSPITALS AND TRAINING OF NURSES AT AMSTERDAM. 403 

Somewhat different from this is the education given in the Associ- 
ation for Nursing. Two physicians, Dr. Van Brakel and Dr. Waller, 
members of the board, give courses for the probationers, who after a 
year are promoted to nurses. 

The Roman Catholic Sisters are trained in the liunneries at 
Maastricht, while the practical lectures at the sick-bed are given in 
the city hospital there by the medical director. The friars visit a 
training school in Germany, where the instruction is given partly by 
a physician, partly by the superior. This course lasts two and one- 
half years. The Lutheran Deaconesses go also to Germany; the 
elementary lectures, however, being given partly by one of the 
physicians in Amsterdam, Dr. Veltkamp, and partly by one of the 
clergymen here. 

As these institutions employ their nurses mainly for private 
nursing, and hospital nursing is of minor importance, it is needless 
to mention along with the number of nurses the number of beds. 
The nursing staff amounts to: Association of Nursing, 30-40; 
Roman Catholic Hospital, 35 ; Friars of St. John de Deo, 19 ; The 
White Cross, 14; St. Bernardus Institute, 6; Lutheran Deaconesses, 
9 ; Protestant Sisters, ?. 

Besides the nurses employed in the hospitals, Amsterdam employs 
more than 100 nurses, not calculating the many nurses, most of them 
formerly employed in one of the hospitals, who nurse in private 
without joining one of the institutions. Most of them nurse one 
patient at a time, except the Protestant sisters, who divide their 
services among many families living in the same district. All the 
above-mentioned institutions furnish their nurses for separate day or 
night nursing and for continued service, the latter especially in cases 
of infectious diseases. All the institutions established for philan- 
thropic purposes furnish on request all aid free of expense. As 
they do not receive any subsidy from the community or the parish, 
they are mainly dependent on donations or legacies from grateful 
patients. That this private nursing is in great demand is proved by 
the following : Nurses of the *' Witte Kruis " gave in 1887 3641 days 
of nursing, the number of which rose in 1891 to 4239 and in 1892 to 
4336; 16 friars gave in 1891 4576 nights of duty; 17 friars in 1892 

5685. 

The night service lasts : Association of Nurses, from 10 o'clock 
p. m. till 9 o'clock a. m., 6 nights in succession, with i night's rest ; 
Protestant Sisters, from 10 o'clock p. m. till 8 o'clock a.m., 5 nights 



404 * HAMILTONl 

in succession, with i night's rest; Witte Kruis, from 10 o'clock p. m. 
till 10 o'clock a. m., 6 nights in succession, with i night's rest. 

Among the various points of difference between these associations 
and the hospitals the most beautiful is certainly that they all assume 
either complete provision for invalid nurses (Roman Catholic Hos- 
pital, Association of Nurses, Friars of St. John de Deo), or at a fixed 
age or in case of disease j>ay a pension (Witte Kruis). 

It is deplorable that the resources of hospitals are not sufficient to 
assume this fair duty. Be the time not far away when a change can 
be made in this respect. 

I finish this report wishing that the future may bring us a National 
Pension Fund for the nursing staff, assuring a lasting appreciation 
for services rendered. 



THE MONTREAL GENERAL HOSPITAL; ITS ORGANI- 
ZATION, HISTORY AND MANAGEMENT. 

With Plans of Surgical Pavilions and New Operating 

Amphitheater. 

By W. F. Hamilton, M. D., C. M., 

Medical Superintendent. 

In the year 1892 the Montreal General Hospital issued its seven- 
tieth annual report, and by the time this Congress will have closed 
seventy-one years will have passed since it was founded. 

On January 30, 1823, in compliance with the petition of John 
Richardson, William McGillivray and Samuel Gerrard, Elsquires, 
presented to the Legislative Council of Lower Canada on the 9th 
day of April, 1822, a charter was granted incorporating the society 
of the Montreal General Hospital, and enduing that society with 
the powers of such a body. 

In 1859, after thirty-six years of operation, it was found that cer- 
tain of the provisions of the original charter were, in practice, highly 
inconvenient, and therefore an amendment of that charter was asked 
for. This amended charter did not differ in any great degree from 
the original one, but made slight alterations with respect to property 
holding and alienating of property, the number, choice and qualifi- 
cation of the governors of the corporation, and the quorum of gov- 
ernors for transaction of business. 



THE MONTREAL GENERAL HOSPITAL. 405 

Before going farther into the history of this institution, it would be 
well to return to a period previous to 1823 and note the steps lead- 
ing up to the petition for the royal charter. 

We find, according to the writings of the late lamented Dr. R. 
Palmer Howard, that in the year 18 19 a great need for increased 
hospital accommodations was felt. The city was rapidly increasing, 
a great influx of immigrants came, and cases of contagious fevers 
and other diseases so overcrowded those institutions which did 
receive them that four rooms were hired in a part of the city known 
as Chaboillez Square, and a temporary hospital was provided by a 
number of philanthropic persons, prominent among whom were the 
Rev. John Bethune, the Rev. Henry Elsson and StafT-Surgeon Dr. 
Blackwood. From this small nucleus great thjngs have come. The 
following year, 1820, April 25th, a meeting of subscribers was held 
in the courthouse for the establishment of a general hospital. These 
subscribers appointed various officers as president, vice-president, 
treasurer and secretary, medical attendants, etc., for the carrying on 
of the work contemplated, and indeed already begun.' 

Another and more convenient place was provided temporarily for 
the care of patients. The citizens of Montreal generously supported 
the early workers in so good a cause, and in 1820 the land upon 
which the hospital now stands was purchased, and over ^£2000 were 
subscribed to erect a suitable permanent building, to be called "The 
Montreal General Hospital." The institution was devoted to " the 
reception of patients of all diseases usually admitted into such 
hospitals in Great Britain, without distinction of religious denomina- 
tion." This has always characterized the admission of patients to 
its wards. 

We have said that in 1820 the present site was purchased. On 
the 9th of June of the following year the corner-stone of the present 
central building was laid, and in less than one year from that date it 
was ready for the reception of patients, of whom 70 were able to find 
accommodation at the same time. During the first year of its exist- 
ence 421 were treated within its walls. The cost of site and building 
amounted to about $25,000. 

During the next nine years the work of the institution made favor- 
able progress. The building, at the end of this time, had become 
inadequate to the accommodation of the patients applying for relief. 
In this year also Hon. John Richardson, president of the governing 
body for the past ten years, died. 



406 HAMILTOK. 

To perpetuate the memofy €i( one vbo had reixiercd such inval- 
ual^e service to the institatiofi, it vas decided to build a wing to the 
hospitaL Accordingly the Richardsoo wiog vas prompdy erected 
in 1831-32, aod the capacity of the hospital increased. 

The presidency of the hospital was now laid upon the Hon. John 
Mobon, who held it until his death in 1835, when^Samud Gerrard, 
Esq., was made president This office was thus faithfully held for 
twenty years. At the end of this period he resigned on the groood 
of advanced age, and the Hon. John Molson succeeded to this office 
in 1856. This officer held the presidential chair for three years only, 
when he was succeeded by Mr. John Redpath. It was in 1869 when 
this devoted member of the board o( governors died, Mr. WiUiam 
Molson succeeded to the position of president 

In 1875 Peter Redpath was appointed to the presidency rendered 
vacant through the death of Mr. William Molson. one of the foun- 
ders of the hospital, and on many occasions a munificent contributor 
to its funds. 

In 1882 he was succeeded by Mr. Andrew Robertson. This 
officer resigned his position on . account of ill-health at the end of 
seventeen years of de\'otion to the interests of the institution as 
treasurer, vice-president and president 

In 1889 the present president, Mr. John Stirling, was appointed, 
and many have been the improvements since that date. 

Let us now take another glance over the history of the institution. 
We have touched upon the fact that the central building and Rich- 
ardson wing have been erected. 

In 1S48-49 the Reid wing on the western i>ortion was erected 
through the munificent gift of the much respected widow of the late 
Hon. Chief Justice Reid. Such an addition gave balance to the 
whole structure, greatly increased the capacity of the institution, and 
served not only as the noblest monument that could be erected to 
his memory, but as an appropriate realization of his oft-expressed 
wishes and sentiments. 

In 1866, through the generosity of Messrs. Wm. Molson and 
J. G. McKenzie, a portion of property in front of the hospital was 
purchased. The buildings situated on it were removed, and a large 
open square in front of the institution was thus secured, adding 
much to the appearance and sanitary condition of the place. This 
open space still remains. 

In 1868 more convenient and suitable provisions were made for 



THE MONTREAL GENERAL HOSPITAL. 4O7 

the treatment of contagious diseases, cases of which had hitherto 
been cared for in the Reid wing without any proper isolation. A 
building capable of receiving about 50 cases, constructed of red 
brick, and at a cost of $10,674, was erected in the rear of the Rich- 
ardson wing. About half the cost of this portion of the institution 
was borne by Mr. William Molson. 

The next addition to the hospital accommodation was that fur- 
nished by what is known as the Morland Wing, erected at a cost of 
about $20,000. It was placed immediately in the rear of the Reid 
wing, on St. Dominique street, as a monument to the memory of 
the late Mr. Thos. Morland, whose zeal and activity in hospital 
affairs were highly esteemed. 

In 1889-90 the question of more suitable arrangements for accom- 
modating the nurses was settled by the addition of a mansard story 
to the central building and the two wings. Excellent bedrooms and 
a large sitting-room, airy and well ventilated, were thus provided, at 
a cost of upwards of $10,000. 

In his report of 1882, the late lamented R. Palmer Howard, secre- 
tary of the Montreal General Hospital, in speaking of the over- 
crowded wards of this institution, asks : "Who amongst the mer- 
chant princes will contribute $100,000 to begin a wing of the new 
hospital, which the governors have been for some years wishing to 
erect, and which will be worthy of the largest and wealthiest city of 
our Dominion? " 

Two years after this report was published the question was fully 
and satisfactorily answered. Lord Mount Stephen contributed 
$50,000, and the bequest of the late David J. Greenshields swelled 
the sum to $90,000. By the time that plans were made and settled 
the sum exceeded the $100,000 asked for, and in June of 1891 the 
work was begun on the site of the new surgical pavilions and ope- 
rating room. The work on these new pavilions was not completed 
until December, 1892, and on the 19th of that month the first patients 
were admitted to these wards. 

We will now turn to speak of the hospital site and buildings. The 
Montreal General Hospital is situated in the midst of the city, and 
occupies the most of a square between Dorchester and Lagauchetiere 
streets. The original building and the Richardson and Reid wings 
are built of Montreal building stone or limestone. It is of plainest 
architecture, and no pretension to beauty or ornateness of design 
has been made. The stone is for the most part smoothly cut, and 



408 HAMILTON. 

the tiaea of the building arc straight. The Morland wing, of more 
reomt cotuiruction, i.i of a more tasteful style, built of dressed Ume- 
Mooe with cmbo9»cd facings. Including basement and nurses' 
qiurten, there are six floors ia all. ' The basement is used as kitcbea 
4Im1 laundry, store and furnace rooms, and beneath the Reid and 
Hoiiand wings the outdoor depanment is sttualed. The first floor 
aflbrds space for one large ward, accommodating fifteen patients: 
offices of medical superintendent and steward, the waiting-rooms, 
and rooms for ihe resident medical staff and lady superintendent. 
The second floor is devoted towards for the patients, with a few 
private rooms. The third floor is also divided into wards, and to 
the Reid wing there is an operating amphitheater and ledu re-room, 
with a aoulhweatern aspect, affording accommodation for about one 
hundred and thirty students. We have already spoken of the upper- 
most flat, tised by the nurses as dormitories, etc. 

We have referred to (he building and opening of two paviiioDS at 
the close of 1892. It is fitting at this point to enter more into detail 
of plan, etc., in speaking of this extension. The original part of 
I he hospital is now long since out of date, and it is only the question 
of a few months when we hope that these old things will have passed 
away and we will have all things new, for the plans of remodeling 
are being arranged and wilt doubtless be executed in the near future. 

The accompanying plana will serve to show the arrangement in the 
new portion of our institution. 

Here are shown the three floors, basement, and first and second 
flats. The material of which these wings is constructed is red pressed 
brick. Each pavilion has two large wards containing twenty-four 
beds each. These wards are light and airy, with a large semicircular 
area or "bow-window" occupying the whole of the end of the ward. 
(We will speak later of the air space to each patient.) 

In connection with each fiat is a large lavatory, containing bath, 
hand basins, slop sink, porcelain washtub, and closets of moat 
improved style, set up on tile floor; the lavatory is finished in 



In the lavatory, the antiseptic solutions, warming tins, bed pans 
and urinals are neady put away on marble shelves especially arranged 
to receive ihem. 

The kitchen contains dumb-waiter, sink, cupboards, refrigerator 
and gas stove and heater. In connection with each public ward there 
are two private wards. These apartments are lighted with incan- 





THE MONTREAL GENERAL HOSPITAL. 4O9 

descent lights of sixteen candle power each, with the exception of 
those two over the operating-room table, which are of fifty candles 
each. 

The surgical amphitheater is sufficiently large to accommodate 
three hundred students. It is a bright and most convenient room, 
with a northwestern aspect. The glass of its main window is of 
cathedral ruby, while that of the others is of the plain variety. A 
large skylight, in addition to the main window, affords ample light for 
all operations. The accompanying plan will make clear the arrange- 
ment of rooms in the amphitheater building. The surgical supply 
room, and the anaesthetizing and instrument room, on the right, and 
surgeon's coat and preparatory rooms, with a recovery room, on the 
left: 

The walls of the operating room are of finely finished white plaster. 
The semicircular portion in front of the students' seats, as well as 
the walls to a height of seven feet from the floor, are finished with 
marble. The floor is made of tiles. 

Several months of experience in this amphitheater with a very 
active surgical service, enables us to speak very highly of the 
appointments in this department. The students see well. The light 
is good both by day and by night, and the facilities for entrance and 
exit of patients are in a high degree satisfactory. 

Ventilation and Heating of New Pavilions, 

In these days of improved and variously planned systems of venti- 
lation and heating, it is of interest to know how so important matters 
are attended to in hospitals. 

The description of these new pavilions would be quite incomplete 
without particular reference to this system now in operation here. It 
is what is known as the plenum system of ventilation^ and I am 
deeply indebted to the architect, Alexander C. Hutchison, Esq., for 
the /bllowing description : 

This system is one by which the air is forced into the wards, enter- 
ing very close to the ceiling and passing out again at the floor, 
thence under the floor to a flue, into the open air. 

For forcing the requisite volume of air into the wards, a pair of 
fans each six feet in diameter by three feet wide, made by Messrs. B. 
F. Sturtevant & Co., of Boston, were installed in the basement of the 
amphitheater building, and operated by a 28-horse power, high 
speed, automatic cut-off engine, the revolutions of the fan being 
arranged for 210 per minute. 



410 HAMILTON. 

From the fans, ducts made in brick work are carried along below 
the basement floor of each pavilion and of the amphitheater building, 
to vertical shafts leading to the several wards and rooms to be vend- 
lated. In each of these large wards there are six of these shafts, 
while in the smaller wards and rooms, only one each. These shafts 
carry the air to the ceiling and there, through an ornamental iron 
casting, discharge it into the ward. To secure uniformity of tem- 
perature and a thorough mixing of air, these shafts, which are built 
in the external walls, have been placed so as not to be opposite each 
other. 

The supply of air is taken through two windows, each 7 feet by 4 
feet, from an open court removed from the dust of the street. 

When the fans are in operation at a speed of 210 revolutions per 
minute, a large volume of air is forced into every room, an actual 
measurement showing the quantity to be 1,182,000 cubic feet per 
hour. At this rate the air in each room would be changed about 
four times every hour, while each patient would be supplied with 
4000 to 5000 cubic feet per hour. 

Extraction of the -/4/r.— The air supply gains access to the wards 
near the ceiling. It then descends to the floor, thence it is carried 
away through gratings placed in the skirtings into ducts below 
the floors, to the extracting shaft in each section of the building, 
/. e., each pavilion and the amphitheater section. 

Each shaft has an area of one square foot to about each 5000 cubic 
feet in the building with which it is connected. They are built of 
brick, and rise about ten feet above the roof. At the bottom of each 
shaft a coil of steam pipes is fixed, and is especially intended for 
rarefying the air, creating a draught when the fans are not in oper- 
ation. 

Warming the Air, — There are no heated coils or radiators in the 
wards. The air is heated at two points (if necessary) in its course 
from the outside of the building to the inner part of the ward. 

We have already spoken of the windows through which the air is 
drawn by the revolving fans. Between the windows and the fans is 
a hot-blast apparatus made by Messrs. B. F. Sturtevant & Co., of 
Boston. This apparatus consists of 7000 feet of one-inch iron pipe, 
arranged in a great number of sections, each section consisting of 
two upright pipes fixed in a cast iron base and connected together 
at the top by a cross pipe. The longest pipe in this apparatus is not 
more than 23 feet, and there is no danger from freezing, however 
rapid the condensation of steam. 



THE MONTREAL GENERAL HOSPITAL. 4II 

The Other point at which the air may be heated on its way to the 
wards is the reinforcing or supplementary heating chamber arranged 
in the basement for each vertical shaft. 

In these chambers are placed cast iron radiators over which the 
air could be forced to flow, when it is found that the fans do not heat 
it sufficiently. These radiators so placed in the whole of the build- 
ing, are equal to about ii,ooo feet of one inch pipe, giving a total 
heating surface, including the piping in the hot-blast apparatus, of 
5666 superficial feet. The flow of air through these chambers is 
under control of the engineer or nurse, who opens and closes the 
valve thereto, by handles worked in the ward, as occasion demands. 

At this date we have passed through one of the coldest winters of 
our Canadian climate. At no time during this season has it been 
necessary to use the reinforcing chambers, nor have all the sections 
in the hot-blast apparatus been heated at the same time. 

Notwithstanding these facts, the whole new department of the 
institution has been well lieated, and the system affords general 
satisfaction. It appears, however, that the expenditure in this 
department has been far beyond the necessity of the case, for 
undoubtedly sufficient heat could have been secured without the 
reinforcing chambers — so far, at any rate, they are superfluous. 

The objections to the system are few. That which suggests itself 
at first is the free motion of dust and smoke. This, however, may 
be reduced to a minimum by proper attention to the court, and in 
special rooms the insertion of gauze in the flues. 

The great advantage of the system is, a free and constant ingress 
of fresh warm air, and the exit of vitiated air, and this without per- 
ceptible draughts. 

Pay Patients in Hospitals, 

One of the subjects for special consideration laid down by the 
committee of this Congress was that of pay patients in hospitals. 
This institution has such a class within its wards almost constantly. 
They may be divided into private pay patients and public pay 
patients. The former occupy single wards at a cost of two dollars 
per day. This does not include medical advice. 

The latter are placed in the public wards and pay only fifty cents 
per day. Under this class come all citizens able to pay^ while all 
strangers are oblij^ed to pay this amount. 

Immigrants to the city are admitted free when needing treatment 
in indigent circumstances. 



412 HAMILTON. 

The admission of sailors is made on recommendation of the 
Department of Customs, which guarantees the payment of ninety 
cents per day on presentation of the account to the Dominion Gov- 
ernment. 

It is a well-established fact that our terms for patients are too low 
if we would wish to be fully remunerated. 

Neither in public wards nor private wards does the income cover 
the expenditure per patient, reckoning the whole current expenses 
on the number of patients treated. 

The revenue from such cases is not large, about $7200 last year, 
while this year upwards of $8500 has been received. 

The Numbers Treated Yearly, 

To indicate the number of cases coming under treatment in the 
Indoor Department, the following figures may be found of interest : 

Indoor : 

For the year ending April 30, 1891, 2035 cases were treated. 

" 30, 1892, 2329 •* 

" 30. 1893, 2359 " 

Outdoor : 
Consultations for year ending April 30, 1891, 30,074. 

30, 1892, 34,220. 
30» 1893, 34,100. 



(( Ik ti >( 

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T/ie Ambulance Service, 

While reference is being made to the number of cases under treat- 
ment, it may be interesting to speak briefly of the ambulance serv- 
ice. Speaking generally it may be said that the service in this 
department is well rendered, both for promptness and efficiency. 
There are two well-equipped ambulances, and in cases of necessity a 
third can be placed upon the street. 

We have spoken of the promptness of this service. Besides the 
readiness with which the ambulance carrying the surgeon maybe got 
out, the highest rate of speed possible through crowded streets is 
secured and maintained, and thus the first aid to the injured in many 
cases is that given by an active, intelligent surgeon. 

The Hospital Orf^anizatio7i and Governing Bodies, 

Under this division of our subject we include the board of gov- 
ernors, the committee of management, and the medical board. The 



THE MONTREAL GENERAL HOSPITAL. 413 

board of governors consists at prcfsent of about four hundred members, 
a few of whom are ladies ; they are either life or elected governors. 
Life governors are those who have paid a sum of one hundred dol- 
lars, and thereafter a yearly amount of twelve dollars. The number of 
elected governors is confined to twelve. There are six of these 
elected yearly. They are appointed by the board of governors and 
corporation for the term of two years. Each such member must pay 
twelve dollars per year. 

Before leaving this part of the subject we will define in a word 
the term corporation mentioned above. Under this term is included 
that body of contributors whose yearly subscriptions are five dollars 
and upwards, whether any other amount has been subscribed or not. 

It is quite impossible for so large a board of governors as that 
now contributing to this institution, to meet for the transaction of 
the business of the same. This board appoints what is termed the 
committee of management, consisting of president, vice-president 
and treasurer, and ten additional members, one of whom is a mem- 
ber of the consulting staff. This committee sits weekly, on afternoon 
of Monday, for the transaction of business in connection with the 
domestic economy of the house, — in a word, to oversee and control all 
matters connected with the management of the hospital At each 
meeting reports are made of the number of patients admitted during 
the week, and the number discharged ; the average daily in the 
house, the number of those treated in the various outdoor depart- 
ments, the number of deaths, with cause of same; and various 
other things incident to the management. The committee of man- 
agement appoints from among its members three who act on what 
is known as the house committee. The function of this committee 
is implied in its name. 

We come to speak next of the medical board. This board con- 
sists of the consulting staff, the physicians and surgeons, and the 
specialists who attend to patients in the hospital. The appointment of 
the members of this board is made by the governors. Any physician 
or surgeon who may have served the hospital in that capacity for 
twelve years is eligible to be elected on the consulting staff. The 
link between the last two and chief governing bodies is that afforded 
by the regulation that one member of the committee of management 
is selected from among the members of the medical board; he holds 
office on both boards. 

In addition to the above outline, which indicates the chief govern- 



414 HAMILTON. 

ing bodies, which are external to the household, we must add a few 
words concerning the internal organization. This is directly under 
the supervision of the medical superintendent ; each department, how- 
ever, has a head. There are the various departments here. The 
nurses' department is directly governed by the lady superintendent. 
The domestic department is under the superintendence of the house- 
keeper and steward. The department of heating and ventilating, 
lighting, plumbing, etc., has a capable engineer at its head. 

The resident house staff consists of medical superintendent, two 
house physicians, three house surgeons, one anaesthetist, and an 
apothecary. We have one non-resident clinical assistant, who acts 
in that capacity in the outdoor department of medicine and gynae- 
cology and indoor gynaecology. The medical superintendent receives 
his appointment from the committee of management. The resident 
house officers are appointed by a vote of the board of governors. 

Turning now to speak of the finances of this institution, we touch 
upon a subject the consideration of which cannot be indulged in 
without feelings of gratitude and pleasure. Ever since 1820, when this 
institution had its beginning, the citizens of Montreal have never &iled 
to support its interests, and that liberality of spirit and gifts which at 
that time was manifested has flowed on in an ever- increasing degree. 
With the increase and extension of the work, the increasing need 
has been supplied — a fact not only satisfactory in itself, but most 
praiseworthy and commendable, speaking as it does of the place 
which the institution has in the hearts of the people. 

The Montreal General Hospital is not a city or civic hospital. The 
support rendered by the municipality is small indeed. It is not a 
denominational institution, though most of its funds are subscribed 
by Protestants. One fact will show that in this sense it is general. 
Last year, 1891-92, the following were the divisions of religious 
bodies : Protestants 1309, Roman Catholics 943, other religions 77. 

The hospital support is mainly derived from private sources. Each 
year collectors are appointed to solicit subscriptions throughout the 
various wards of the city. Then ordinary donations afford another 
source of revenue. The Provincial Government gives a grant of from 
two to five thousand dollars yearly. 

The interest on capital invested, the revenue from patients, the fees 
of medical students, the rents, and contents of poor boxes, make up 
a yearly income of about fifty thousand dollars. This amount is not 
sufficient to defray the current expenses, which are yearly increasing. 



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THE ROYAL VICTORIA HOSPITAL, MONTREAL. 4I5 

last year amounting to fifty-five thousand dollars, and upward, while 
this year it will find us with an expenditure of upwards of seventy 
thousand dollars to report. 

We must now bring to a close this fragmentary paper, written as it 
has been in the midst of a most active and busy Hfe within the walls of 
the institution. We have sought to present a few of the general points 
of interest concerning the history, organization, management and 
capacity of the institution, with plans of the new surgical pavilions. 
The writer's chief regret is the lack of time at his disposal ; otherwise 
far more interesting and instructive matter would have been placed 
before this Congress of Charities, Correction and Philanthropy, and 
the Montreal General Hospital would have been seen through it 
more as it really is. 



THE ROYAL VICTORIA HOSPITAL, MONTREAL. 

By Jno. J. RoBSON, Secretary, 

The accompanying illustration shows a front view of the hospital. 
The building is situated on the eastern slopes of Mount Royal, over- 
looking the city •and the St. Lawrence river. 

The institution owes its origin to the munificence of two distin- 
guished Canadians, Lord Mount Stephen and Sir Donald Smith, 
K. C. M. G. 

The buildings have been designed and the working drawings pre- 
pared by H. Saxon Snell, F. R. L B. A., London, England, after 
consultation with, and receiving the final approval of the medical 
faculty of McGill University. 

The narrowness of the site gave rise to much difficulty in designing 
the buildings, but a far greater problem had to be solved in conse- 
quence of the uneven nature and steepness of the ground, situated 
on a mountain (Mount Royal) which rises no less than 180 feet in 
its length and from 30 to 80 feet in its breadth ; this difficulty, how- 
ever, has been overcome by making the main entrance at the back 
midway up the slope on which the main building stands, thus per- 
mitting one floor of the various blocks to be reached on the same 
level. 

The ward blocks are ranged along the northeast and southwest 
boundaries ; between these is the administration block, in which are 



4l6 ROBSON. 

also the out-patients' department and receiving rooms. The entrance 
to this last building is approached by carriage and footways from 
Pine Avenue. The center portion contains, on the ground floor, the 
board room, secretary's office, medical officer*s sitting and bed rooms, 
etc., and the entrance hall and porter's room and principal staircase. 
The upper floors contain a large number of bedrooms for the nurses, 
together with their common sitting and dining rooms, library, linen 
and bath rooms, lavatories, etc 

The lady suj>erintendent*s apartments are placed on the first floor. 
The general kitchen for the whole of the building is placed on the top- 
most floor of the center of the building, and also the scullery and acces- 
sory stores, larders, pantries, etc. The ward maids and other servants' 
rooms are in the adjoining roof floors. A service staircase and coal 
and food lifts communicate with all floors, so that the meals can be 
distributed to the wards in each and every block without difficulty 
or undue delay, or the necessity of ascending and descending stair- 
cases. 

The rear extension of the block contains, on the basement floor, the 
stores and men's bedrooms, and on the ground floor the dispensary 
and also the medical officer's and lady superintendent's offices. On 
the upper are additional nurses' bedrooms. The two large project- 
ing blocks on the southwest and northeast boundaries each contain 
three large wards, I23'X26'6" and 14' high, for the accommodation 
of 30 patients in each. The northeast block is devoted to medical 
and the southwest block to surgical patients. Attached to each large 
ward are four rooms comprising the ward-kitchens and day-room, 
separation ward and private ward. The bath-rooms and ward offices 
are contained in the round towers at the ends of the wards. 

Adjoining each ward block is the staircase block containing a 
Ijroad and easy-going staircase, patients' lift, patients' clothing and 
linen stores, etc. 

In the center is the large ventilating shaft which draws the foul air 
from all the adjoining wards. Up the center of this is carried the 
smoke shaft from the boilers in the basement, which materially assists 
the draught power. 

Beyond the staircase block in the southwest (surgical) side, are 
the wards for women and children, 28'X4o' each. 

The last block on this side is the surgical theater, which will seat 
250 students; adjacent to which are the surgeons', nurses', anaesthetic 
and after-recovery rooms. 




fco^o ^^oq^ /v./*/^ - 



THE ROOSEVELT HOSPITAL. 4I7 

Returning to the buildings on the northeast boundary (medical 
side), on the first floor of level of staircase block is a children's ward 
for 10 beds, and on the top floors are male and female erysipelas 
wards, comprising 4 male and 4 female wards, each for one bed, with 
ward kitchen and nurses' room adjoining. 

The next block is the medical theater for 200 students ; the adjoin- 
ing professors' private room and patients' waiting-room being on 
ground floor of the staircase block. 

Beyond the theater is the pathological block, 88'X4o' (see accom- 
panying ground plans), containing on the ground floor inquest and 
waiting rooms, mortuary and working rooms. The second floor is 
occupied by the lower part of the demonstration theater, the prep- 
aration room, museum and director's office. The top floor, which 
connects with the main floor of the hospital, contains the upper part 
of the demonstration theater, bacteriology, photography and path- 
ological chemistry rooms. 

The drainage has been designed upon a carefully arranged system, 
with glazed earthenware pipes jointed in cement and laid on beds of 
cement concrete in trenches excavated in solid rock. Manholes and 
inspection pits, etc., have been liberally provided in accordance with 
the latest modern requirements. 



HISTORY AND DESCRIPTION OF THE ROOSEVELT 

HOSPITAL. 

By James R. Lathrop, Superintendent 

The Roosevelt Hospital is located on the block bounded by Fifty- 
eighth and Fifty-ninth streets and Ninth and Tenth avenues, in New 
York City. It owes its existence to the bequest of James H. Roose- 
velt, who was born in New York on November 10, 1800, and died on 
November 30, 1863, in the city of his birth. By will, executed on 
March 13, 1854, he provided, after making certain special bequests, 
that *' all the rest and residue of his personal estate " should be 
employed ** for the establishment in the city of New York of a hos- 
pital for the reception and relief of sick and diseased persons and 
for its permanent endowment." The execution of that trust was left 
to the direction of a board of nine trustees; ^s^^ exofficiOy by virtue 



t 



I 



418 LATHROP. 

of their being presidents of humane institutions in the city of New 
York, and four personal friends designated by name. The president 
of the hospital at this time is the only surviving member of the 
original board. 

It is not known that Mr. Roosevelt ever had a very clear idea as 
to the character of the buildings which would form the group of the 
hospital structure. He was satisfied to leave that matter to the 
determination of the nine trustees whom he designated for the execu- 
tion of his will. 

In February, 1864, the Legislature of the State granted an act of 
incorporation to the hospital. The board of trustees was then duly 
organized ; soon a building committee was appointed, and the 
principles of hospital construction, as they were then understood, 
were made the subject of earnest study by Dr. Stephen Smith, 
who was selected by the board for that purpose. The doctor 
visited many ot the principal hospitals in this country and in 
I Europe, and, as a result of careful deliberation, plans were adopted 

and the work of building began in 1869. The opening exercises, 
on November 2, 1871, were held in one of the wards of the 
building known as the Medical Pavilion, and located immediately 
east of the Administration Building, which was at that time unfin- 
ished. The purpose of the trustees was that the latter building 
should form the center of a group designed to eventually cover the 
block upon which the hospital stands. The funds at the disposal of 
the board enabled them, at the outs